Additive Value of Right Ventricular Global Longitudinal Strain to a Conventional Echocardiographic Parameter to Improve Prognostic Value in Intermediate-Risk Pulmonary Embolism

BACKGROUND: Right ventricular (RV) dysfunction has been identified as a prognostic marker for adverse events in patients with intermediate-risk pulmonary embolism. We hypothesized that right-sided strain parameters have additive value to conventional echocardiographic parameters to further risk-stratify patients for mortality. METHODS AND RESULTS: This is a retrospective cohort study of patients with intermediate-risk pulmonary embolism between 2010 and 2018. All-cause 30-day mortality was evaluated. Echocardiographic strain parameters and conventional RV measurements were compared between survivors and nonsurvivors. Two hundred fifty-one patients were analyzed. Mortality at 30 days was 12.4%. Image quality was sufficient for RV strain analysis in 230 patients (91.6%). Right to left ventricular end-diastolic diameter ratio (RV/LV ratio) (odds ratio [OR], 1.490 [95% CI, 1.120–1.990]) and RV global longitudinal strain (RVGLS) (OR, 0.742 [95% CI, 0.605–0.910]) were independently associated with 30-day mortality. Using RVGLS and RV/LV ratio in an additive fashion, we found that 99 patients with a high RVGLS (>17.7%) and low RV/LV ratio (<1.03) had a 30-day mortality of 1.0%. Conversely, 39 patients with a low RVGLS (≤17.7%) and high RV/LV ratio (≥1.03) had a 30-day mortality of 46.2%. Kaplan–Meier analysis depicted the significantly different prognosis among the groups (P<0.001). CONCLUSIONS: The combined evaluation of RVGLS and RV/LV ratio is a practical method of evaluating RV dysfunction. Using both parameters in patients with intermediate-risk pulmonary embolism identifies those at highest and lowest risk of shortterm mortality. This approach offers promise for improved risk stratification and guidance of treatment pathways.