Predictive Power of N-terminal Prohormone of Brain Natriuretic Peptide on Admission and on Discharge for Short- and Long-term Clinical and Echocardiographic Outcomes in Patients With Pulmonary Thromboembolism

Document Type: Original Article


1 Atherosclerosis Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran.

2 Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, IR Iran..

3 Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, IR Iran.

4 Research Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, IR Iran.


Background: This prospective case-series study was conducted to determine the predictive power of the N-terminal prohormone of brain natriuretic peptide (NT-proBNP) on shortand long-term outcomes in patients with pulmonary thromboembolism (PTE).
Methods: Ninety-two patients (age = 60 ± 1.97 y, 54.7% male) diagnosed with PTE were recruited. NT-proBNP levels and echocardiographic indices were measured and recorded. The primary endpoint was considered to be 3-month PTE-related deaths and long-term adverse outcomes including 1-year all-cause mortality, rehospitalization due to the recurrence of PTE, right ventricular dysfunction, and pulmonary hypertension.
Results: The serum NT-proBNP level and the right ventricular diameter were significantly higher in the patients with adverse outcomes than in the outcome-free patients. Several significant correlations were found between NT-proBNP levels and echocardiographic indices. During a mean follow-up time of 12 months, 1 patient suffered PTE relapse, 15 patients had right ventricular dysfunction and pulmonary hypertension, and 2 patients expired. Age was an independent value in the prediction of the adverse outcome (OR: 1.064, 95% CI: 1.01 to 1.11). Discharge NT-proBNP levels, calculated according to a multiple cutoff point strategy for heart failure, in the PTE patients with adverse outcomes was 2.36 fold that in the outcome-free patients. The optimal value for discharge NTproBNP according to the receiver operating characteristic analysis was 327 pg/mL, with a sensitivity of 80% and a specificity of 43%.
Conclusions: NT-proBNP measurement during the course of PTE, especially on discharge, may have a role as an easy-to-use diagnostic tool for determining patients with poor prognoses.


1. Klok FA, Zondag W, van Kralingen KW, et
al. Patient outcomes after acute pulmonary
embolism: a pooled survival analysis of
different adverse events. American journal
of respiratory and critical care medicine
2. Members ATF, Torbicki A, Perrier A, et al.
Guidelines on the diagnosis and
management of acute pulmonary embolism:
the Task Force for the Diagnosis and
Management of Acute Pulmonary Embolism
of the European Society of Cardiology
(ESC). European heart journal
3. Tapson VF. Advances in the diagnosis and
treatment of acute pulmonary embolism.
F1000 medicine reports 2012;4
4. Kreit JW. The impact of right ventricular
dysfunction on the prognosis and therapy of
normotensive patients with pulmonary
embolism. Chest 2004;125(4):1539-45.
5. Schoepf UJ, Kucher N, Kipfmueller F, et al.
Right ventricular enlargement on chest
computed tomography: a predictor of early
death in acute pulmonary embolism.
Circulation 2004;110(20):3276-80.

6. Dellas C, Lankeit M, Reiner C, et al. BMIindependent inverse relationship of plasma
leptin levels with outcome in patients with
acute pulmonary embolism. International
Journal of Obesity 2013;37(2):204.
7. Becattini C, Vedovati MC, Agnelli G.
Prognostic value of troponins in acute
pulmonary embolism: a meta-analysis.
Circulation 2007;116(4):427-33.
8. Lankeit M, Dellas C. Panzenbö ck A, SkoroSajer N, Bonderman D, OIschewski M, et al.
Heart-type fatty acid-binding protein for risk
assessment of chronic thromboembolic
pulmonary hypertension. Eur Respir J
9. Zondag W, Agterof MJ, Schutgens RE, et al.
Repeated NT-proBNP testing and risk for
adverse outcome after acute pulmonary
embolism. Thrombosis and haemostasis
10. Pruszczyk P, Kostrubiec M, Bochowicz A,
et al. Nterminal pro-brain natriuretic
peptide in patients with acute pulmonary
embolism. European Respiratory Journal
11. Vavera Z, Vojáček J, Pudil R, et al. NTproBNP levels on admission predicts
pulmonary hypertension persistence in
patients with acute pulmonary embolism.
Cor et Vasa 2012;54(1):e27-e31.
12. Dores H, Fonseca C, Leal S, et al. NTproBNP for risk stratification of pulmonary
embolism. Revista Portuguesa de
Cardiologia (English Edition)
13. Kostrubiec M, Pruszczyk P, Kaczynska A, et
al. Persistent NT-proBNP elevation in acute
pulmonary embolism predicts early death.
Clinica chimica acta 2007;382(1-2):124-28.
14. Alonso-Martínez JL, Annicchérico-Sánchez
FJ, Urbieta-Echezarreta MA, et al. Nterminal Pro-B type natriuretic peptide as
long-term predictor of death after an acute
pulmonary embolism. Medicina Clínica
(English Edition) 2015;144(6):241-46.
15. Seyyedi Sr, Jenab Y, Tokaldany ML, et al.
Syncope paradox in the outcome of patients
with pulmonary thromboembolism:
shortterm and midterm outcome. The
clinical respiratory journal 2016;10(1):90-
16. Jenab Y, Alemzadeh-Ansari MJ, Fehri SA,
et al. Effect of delay in hospital presentation
on clinical and imaging findings in acute
pulmonary thromboembolism. The Journal
of emergency medicine 2014;46(4):465-71.
17. Wicki J, Perrier A, Perneger TV, et al.
Predicting adverse outcome in patients with
acute pulmonary embolism: a risk score.
Thrombosis and haemostasis
18. Qanadli SD, El Hajjam M, Vieillard-Baron
A, et al. New CT index to quantify arterial
obstruction in pulmonary embolism:
comparison with angiographic index and
echocardiography. American Journal of
Roentgenology 2001;176(6):1415-20.
19. Venkatesh SK, Wang SC. Central clot score
at computed tomography as a predictor of
30-day mortality after acute pulmonary
embolism. Annals Academy of Medicine
Singapore 2010;39(6):442.
20. Chan CM, Woods C, Shorr AF. The
validation and reproducibility of the
pulmonary embolism severity index. Journal
of Thrombosis and Haemostasis
21. Righini M, ROY PM, Meyer G, et al. The
Simplified Pulmonary Embolism Severity
Index (PESI): validation of a clinical
prognostic model for pulmonary embolism.
Journal of thrombosis and haemostasis
22. Porapakkham P, Porapakkham P, Zimmet H,
et al. B-type natriuretic peptide–guided heart
failure therapy: a meta-analysis. Archives of
Internal Medicine 2010;170(6):507-14.
23. Morrison LK, Harrison A, Krishnaswamy P,
et al. Utility of a rapid B-natriuretic peptide
assay in differentiating congestive heart
failure from lung disease in patients
presenting with dyspnea. Journal of the American College of Cardiology
24. McCullough PA, Nowak RM, McCord J, et
al. B-type natriuretic peptide and clinical
judgment in emergency diagnosis of heart
failure: analysis from Breathing Not
Properly (BNP) Multinational Study.
Circulation 2002;106(4):416-22.
25. Berger R, Huelsman M, Strecker K, et al. Btype natriuretic peptide predicts sudden
death in patients with chronic heart failure.
Circulation 2002;105(20):2392-97.
26. Omland T, Persson A, Ng L, et al. Nterminal pro-B–type natriuretic peptide and
long-term mortality in acute coronary
syndromes. Circulation 2002;106(23):2913-
27. Maisel AS, Koon J, Krishnaswamy P, et al.
Utility of B-natriuretic peptide as a rapid,
point-of-care test for screening patients
undergoing echocardiography to determine
left ventricular dysfunction. American heart
journal 2001;141(3):367-74.
28. Etesamifard N, Shirani S, Jenab Y, et al.
Role of clinical and pulmonary computed
tomography angiographic parameters in the
prediction of short-and long-term mortality
in patients with pulmonary embolism.
Internal and emergency medicine
29. Kucher N, Printzen G, Doernhoefer T, et al.
Low pro-brain natriuretic peptide levels
predict benign clinical outcome in acute
pulmonary embolism. Circulation
30. Becattini C, Agnelli G, Germini F, et al.
Computed tomography to assess risk of
death in acute pulmonary embolism: a metaanalysis. European Respiratory Journal
31. Sanchez O, Trinquart L, Colombet I, et al.
Prognostic value of right ventricular
dysfunction in patients with
haemodynamically stable pulmonary
embolism: a systematic review. European
heart journal 2008;29(12):1569-77.
32. Jenab Y, Lotfi-Tokaldany M, AlemzadehAnsari M-J, et al. Correlates of syncope in
patients with acute pulmonary
thromboembolism. Clinical and Applied
Thrombosis/Hemostasis 2015;21(8):772-76.