• 1. A 33 year old female patient admitted to the ICU with confirmed pulmonary embolism. It was noted that she had elevated serum troponin level. Does this indicate that she had a cardiac event? Is their any prognostic value for this?

Prognostic Value of Troponins in AcutePulmonary Embolism

A Meta-Analysis

Name Of study

publishes a standard for providing basic and advanced life support, including standards for proper performance of cardiopulmonary resuscitation (CPR)

• 1. Write the study name• 2. Study type Interventional vs observational• 3. Outcome• 6. Time period• 7. Sample size• 8. Randomization• 9. Resutls and its detials.. age groups,,,etc• 10. Conclusions from the results

• Prognostic Value of Troponins in AcutePulmonary Embolism (Meta Analysis)

• Observational vs Interventional

Study type

• primary objective: to assess whether High serum troponins are associated with Death in patients with acute pulmonary embolism (short term mortality)

• Secondary objectives: to assess whether High serum troponins are associated with Death (resulting from Pulmonary Embolism) or adverse outcome events (i.e shock, need for thrombolysis, endotracheal intubation, catecholamine infusion, cardiopulmonary resuscitation, or recurrent pulmonary embolism).

• Primary outcome : Whether elevated serum troponin levels identify patients with acute pulmonary embolism at high risk of short-term mortality or adverse outcome is undefined.

The methods for this meta-analysis are in accordance with “Meta-Analysis of Observational Studies in Epidemiology: A Proposal for Reporting.

1. Search periods from Jan 1998 till Nov. 2006

2. ((key word)) [Pulmonary embolism and Troponin] used in MEDLINE and EMBASE

3. Not Limited to english language

4. Only full Article were considered for analysis??

• (1985 patients)

1. Study design2. Patients (number of included patients, mean age, gender)3. Methods for diagnosis of pulmonary embolism4. Hemodynamic status in the study5. Treatment used for pulmonary embolism6. troponin assays (name of the assay, type of examined

troponin [I or T], cutoff level, timing of determination, and overall troponin-positive patients)

7. Primary end points (number of patients with the primary end point among troponin-positive or -negative patients

8. Secondary end points among troponin-positive and -negative patients).

What are the type of selected study?Is it Case Control ?Crossectional ?Cohort?

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For 5 of these studies, thenumbers of patients who had died or had experienced anadverse outcome event were obtained by contacting theauthors

• Overall 122 of 618 patients with high troponin levels died (19.7%; 95% confidence interval [CI], 16.6 to 22.8) compared with 51 of 1367 with normal troponin levels (3.7%; 95% CI, 2.7 to 4.7).

• Is it significant difference?

16.6% 22.8%

2.7% 4.7%

• In 8 prospective studies (645 patients) reported on deaths resulting from pulmonary embolism. Overall, 40 events were observed:

• 34 in 207 patients with High troponin (16.4%; 95% CI, 11.4 to 21.4)

• 6 in 438 with normal troponin levels (1.4%; 95% CI, 0.8 to 1.9)

• Conclusion: Elevated troponin levels were associated with a high risk of (early) death resulting from pulmonary embolism (OR, 9.44; 95% CI, 4.14 to 21.49)

• How they collect the death incidence data?Some study account:• In hospital death only? (not follow up the

patient)Other study account• In hospital death and include Out side the

hospital death? (up to 100 days)

They considered death and adverse outcome events occurring in the short-term follow-up (in hospital or 30 days)??

• Are Assay used to measure troponin are similar?

3 different assays for troponin T were used With different cutoff points for abnormal levels.5 different assays for troponin I were usedWith different cutoff points for abnormal levels.

• Among studies using the same troponin assay, ORs for mortality were higher in studies using higher troponin cutoffs

• both I and T, were associated with a high risk of short-term death

• result was consistent for either troponin I (OR, 4.01; 95% CI, 2.23 to 7.23) or troponin T (OR, 7.95; 95% CI, 3.79 to 16.65).

• Is there significant difference between TI &TT?

• Conclusion: elevated troponin levels were associated with a high risk of adverse events during the in-hospital phase (OR, 7.03; 95% CI, 2.42 to 20.43)

• Elevated troponin levels were significantly associated with death (short term) (odds ratio [OR], 5.24; 95% CI, 3.28 to 8.38), with death resulting from pulmonary embolism (OR, 9.44; 95% CI, 4.14 to 21.49), and with adverse outcome events (OR, 7.03; 95% CI, 2.42 to 20.43)

• Elevated serum troponins identify a subgroup of patients with acute pulmonary embolism at high risk of in-hospital death and adverse outcome events.

• The results of this meta-analysis suggest a role for troponin in the selection of hemodynamically stable patients with a worse outcome who could potentially benefit from a more aggressive treatment.

• These findings identify troponin as a promising tool for rapid risk stratification of rapid risk stratification of patients with pulmonary embolism. patients with pulmonary embolism. Prospective randomized studies are needed to evaluate the clinical benefits of more aggressive treatments in patients with pulmonary embolisms and elevated troponin levels.

Some missing points• Some investigators believe that meta-analyses

may be as reliable as randomized controlled trials, whereas others believe that the technique should be used only as an alternate to randomized trials. However, in the absence of a large randomized controlled study, a meta-analysis of multiple smaller studies may be the best source of information to answer a specific question.

Critical Appraisal Points

• Are the results of the study valid ?• What were the results ?• Will the results help me in caring for

my patients ?

Are the results of the study valid?

• Did the meta-analysis address a focused clinical question ? – yes , about the prognostic value of troponin

•Where the criteria used to select articles for inclusion appropriate ? !

• Is it unlikely that important, relevant studies were missed ?– no ! Why ?• What about the time before the Time period

of the collected studies !• What about using other search words in

searching for the studies !• What about selection of the full text study

only!

• Was the validity of the included studies appraised ?– Yes , according to Egger’s quality

checklist .

• Were the results similar from study to

study ?– Homogenecity ?!

• What were the results ?

• What are the overall results of the review ?• How precise were the results ?

A: next on the figures .

Will the results help me in caring for my patient?

• Can the results be applied to my patient care ?– Yes ,– It is the best available evidence. – It is better than every individual study in

the analysis .–What about the age group !!

• Where all clinically important outcomes considered ?– Yes ;• Death• Any adverse outcome :

– Shock– Need for thrombolytic– Endo treacheal intubation – Catecholamine infusion for sustained hypotension – Cardiopulmonary resuscitation – Recurrent pulmonary embolism

For my 33 year-old patient

• Is their any prognostic value for raised troponin ? – yes , it indicates poor prognosis

• Does this indicate that she had a cardiac event?– +/- we need a specific article about this