Figures
- FIGURE 1
PRISMA diagram showing literature search and selection of right ventricular dysfunction (RVD) in pulmonary embolism (PE) articles [11]. A total of 6402 articles were identified (1757 duplicates removed). 4675 articles were screened by title and abstract with 251 articles determined for eligibility. 196 articles were excluded, leaving a total of 55 articles that were included in the systematic review. VQ: ventilation/perfusion; CT: computed tomography; RVD: right ventricular dysfunction; TTE: transthoracic echocardiography.
- FIGURE 2
Forest plots for studies assessing right ventricular dysfunction (RVD) in pulmonary embolism (PE) for a) combined adverse events, b) all-cause mortality outcome and c) PE-related mortality outcome. Dashes (–) represent missing data. All weights are from the random-effects model. References can be found in the data supplement. CI: confidence interval; DL: DerSimonian and Laird. #: Yates correction.
- FIGURE 3
Meta-analysis of studies assessing right ventricular dysfunction (RVD) in pulmonary embolism (PE) for haemodynamically stable patients at intermediate risk of outcomes. a) Combined adverse events. b) All-cause mortality. c) PE-related mortality. Dashes (–) represent missing data. All weights are from the random-effects model. References can be found in the data supplement. CI: confidence interval; DL: DerSimonian and Laird.
- FIGURE 4
Individual measures of right ventricular dysfunction (RVD) showing the pooled odds ratios of a) decreasing tricuspid annulus plane systolic excursion (TAPSE) per mm on combined adverse events, b) decreasing TAPSE per mm on all-cause mortality, c) increasing right ventricular to left ventricular diameter ratio (RV/LV) per 1 unit change on combined adverse events, d) increasing RV/LV per 1 unit change on all-cause mortality, e) increasing pulmonary artery systolic pressure (PASP) per 10 mmHg on combined adverse events and f) increasing PASP per 10 mmHg on all-cause mortality. All weights are from the random-effects model. References can be found in the data supplement. CI: confidence interval; DL: DerSimonian and Laird.
Tables
- TABLE 1
Summary characteristics of articles included in the systematic review
Study characteristics Number (%) Cohort (n=55), n (%) 54 (98.2) Case control (n=55), n (%) 1 (1.8) Prospective (n=54), n (%) 32 (58.2) Multicentre (n=55), n (%) 19 (34.5) Aim of study to assess TTE (n=55) 29 (52.7) Patient characteristics Number of haemodynamically stable patients with TTE (n=53), n 17 090 Number of haemodynamically stable patients with TTE per study (n=53), median (IQR) 179 (96–462) Female study patients (n=52), n (%) 8975 (52.8) Male study patients (n=52), n (%) 8036 (47.2) Number of patients with RVD (n=44), n (%) 5399 (37.8) Number of patients with no RVD (n=44), n (%) 8889 (62.2) Geographic region (n=55) Asia/Oceania 13 (23.6) Europe 31 (56.4) Americas 11 (20.0) PE risk group in study (n=55) Low and intermediate risk 44 (80.0) Intermediate risk 5 (9.1) All risk 6 (10.9) RVD definition (n=55) Composite RVD definition 37 (67.3) Individual variable RVD definition 18 (32.7) Time to TTE (n=40) ≤24 h 11 (27.5) ≤48–72 h 29 (72.5) Primary outcome studied (n=55) Combined adverse events 31 (56.4) All-cause mortality 19 (34.5) PE-related mortality 5 (9.9) Outcomes studied (n=55) Combined adverse events 37 (45.7) All-cause mortality 27 (33.3) PE-related mortality 17 (21.0) Follow-up (n=55) In hospital or <14 days 31 (56.3) 14–30 days 24 (43.7) High-risk patients are defined by the presence of haemodynamic instability, intermediate-risk patients are haemodynamically stable but have a simplified pulmonary embolism severity index of >0 and may have evidence of right ventricular dysfunction (RVD) or positive cardiac biomarkers. Low-risk patients are defined as being haemodynamically stable with no evidence of RVD or abnormal cardiac biomarkers [3]. IQR: interquartile range; PE: pulmonary embolism; TTE: transthoracic echocardiogram.
- TABLE 2
Subgroup analysis showing the difference between study design for the studies with combined adverse events, all-cause mortality and pulmonary embolism (PE)-related mortality
Number of studies Pooled effect size (95% confidence interval) I2 (%) Q statistic Combined adverse events Prospective 19 3.81 (2.02–7.21) 57.2 0.635 Retrospective 10 3.04 (2.44–3.80) 0 TTE study 14 3.70 (2.60–5.28) 47.1 0.473 Non-TTE study 15 2.89 (2.09–3.99) 0 TTE <24 h 7 3.74 (2.38–5.88) 54.6 0.439 TTE 24–72 h 11 3.03 (1.92–4.77) 0 Outcomes in hospital or <14 days 18 3.43 (2.61–4.49) 0.4 0.574 Outcomes <30 days 11 3.26 (2.12–5.02) 50.7 Published before 2014 ESC PE guidelines 18 3.56 (2.66–4.76) 6.3 0.383 Published after 2014 ESC PE guidelines 11 3.07 (2.07–4.54) 46.3 AHRQ study quality fair or poor 20 3.45 (2.54–4.69) 15.4 0.603 AHRQ study quality good 9 3.13 (2.11–4.65) 47.0 All-cause mortality Prospective 14 1.95 (1.56–2.44) 0 0.543 Retrospective 19 2.48 (1.62–3.81) 47.1 TTE study 13 2.13 (1.74–2.58) 0 0.462 Non-TTE study 11 2.50 (1.36–4.58) 34.1 TTE <24 h 5 1.95 (0.84–4.54) 0 0.976 TTE 24–72 h 14 2.00 (1.55–2.58) 33.9 Outcomes in hospital or <14 days 14 2.88 (2.10–3.93) 15.9 0.011 Outcomes <30 days 10 1.70 (1.35–2.12) 0 Published before 2014 ESC guidelines 16 2.10 (1.68–2.63) 0 0.619 Published after 2014 ESC guidelines 7 2.06 (1.38–3.08) 52.8 AHRQ study quality fair or poor 14 2.26 (1.58–3.24) 38.0 0.880 AHRQ study quality good 10 2.06 (1.59–2.67) 0 PE-related mortality Prospective 13 3.36 (2.31–4.88) 0 0.103 Retrospective 4 7.37 (3.30–16.46) 0 TTE study 12 4.79 (2.92–7.86) 19.8 0.452 Non-TTE study 5 3.01 (1.64–5.54) 0 TTE <24 h 5 5.56 (1.74–17.74) 0 0.696 TTE 24–72 h 7 4.12 (2.23–7.63) 30.8 Outcomes in hospital or <14 days 9 3.61 (2.04–6.38) 0 0.392 Outcomes <30 days 8 6.05 (2.96–12.37) 49.8 Published before 2014 ESC guidelines 13 3.07 (2.12–4.45) 0 0.010 Published after 2014 ESC guidelines 4 12.16 (5.30–27.91) 0 AHRQ study quality fair or poor 7 8.25 (2.98–22.88) 36.1 0.122 AHRQ study quality good 10 3.32 (2.28–4.85) 0 AHRQ: Agency for Healthcare Research and Quality; ESC: European Society of Cardiology; TTE: transthoracic echocardiogram.
Supplementary Material
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Supplementary material ERR-0120-2022.SUPPLEMENT
