The relationship of right heart dysfunction and NT-probnp levels with survival in cancer patients with newly diagnosed pulmonary thromboembolism

Purpose: Pulmonary embolism severity index (PESI) has been used to predict prognosis in patients with pulmonary thromboembolism (PTE). The component of "being diagnosed with cancer" is one of the items used in scoring and scored highest after the component of "having an impaired consciousness". In addition, its impact results in a poor prognosis score. From this point of view, we aimed to investigate the effects of clinical findings, electrocardiography (ECG) and echocardiography (ECHO) (in regards to right ventricular functions), lactate, blood gase analyze, troponin, d-dimer and NT-proBNP levels on prognosis in cancer patients diagnosed with PTE. The purpose of this study was to compare the prognostic values of PESI score and clinical and laboratory markers in cancer patients and to be able to identify additional scoring specific to cancer patients for PESI. Materials and Methods: This prospective and cross-sectional clinical study was conducted in the Department of Emergency Medicine of Cukurova University Medical School between January 1, 2019 and June 30, with all cancer patients older than 18 who had admitted to the Emergency Service and who had given written consent to participate. In addition to the routine tests (hemogram, biochemistry including troponine T, blood gase analyses) which were performed initially for diagnosing, D-dimer, lactate and NT-proBNP were also assayed. The demographic data and laboratory findings, ECG and ECHO results of the patients were evaluated as well as the treatment they had received, their hospitalization status, length of stay, and mortality within the 1st hour, 24th hour, 1st month and 1-3 months were all evaluated. Findings: 53 cancer patients who had newly developed pulmonary thromboembolism were included in the study. 28 (52.8%) of the patients were males. The mean age of the patients was 62.80±12.89 years, 30.2% of whom (n=16) were between 70 and 79 years old. Thirteen (24.5%) patients died. Three (23.0%) (n=3) patients died in the first 24 hours, seven (53.9%) died in the first month, and three (23.1%) patients died between 1-3 months. The differences between the age groups (p=0.259) and mean age (p=0.052) of the patients and mortality findings were not statistically significant (p>0.05). Lung cancer with 21 (39.6%) patients was the most common cancer in the study. Thirty-three (62.3%) of the patients had heart failure, 25 (47.2%) patients had chronic lung disease and 47 (88.7%) patients had impaired consciousness. Thirty-one (58.5%) patients had a pulse rate over 110/minute, 40 (75.5%) patients' systolic blood pressures were lower than 100 mmHg, 31 patients' respiratory rate were above 30/minute and 34 (64.2%) patients had oxygen desaturation (below 90% ). According to PESI scores, eight (15.1%) of the patients were in Class 2, 23 (43.4%) were in Class 3, 12 (22.6%) were in Class 4, and 10 (18.9%) were in Class 5 as the highest-risk group. The cut-off value calculated for D-dimer was 24.28 pg/dl, with a sensitivity of 76.92%, specificity of 82.5%, the AUC value was 0.764. The efficiency of the D-dimer variable in distinguishing mortality was found to be statistically significant (p=0.003). The cut-off value calculated for blood pH was 7.3, with a sensitivity of 69.23%, specificity of 85.0% and the AUC value was 0.758. The efficiency of blood pH value in distinguishing mortality was statistically significant (p=0.004). The cut-off value for lactate was 3, with a sensitivity of 46.15% and specificity of 77.5, and the AUC value was 0.615. It was found that lactate levels 3 and above, increased the mortality rate but not statistically significant (p=0.242). The cut-off value of Troponin T was 47.49, with a sensitivity of 69.23%, specificity of 68.42% and the AUC value was 0.638. The efficiency of Troponin T in distinguishing mortality was not found to be statistically significant (p=0.140). The cut-off value which was calculated for Nt-proBNP was >1340, its sensitivity was 92.31, its specificity was 70.0 and the AUC value was 0.723. The efficiency of Nt-pro BNP variable in distinguishing mortality was found to be statistically significant (p=0.002). When the ECGs of the patients were evaluated, 8% of them were normocardic sinus, 16% had sinus tachycardia, 14% had s1q3t3, 4% had right bundle branch block, 4% had high rate atrial fibrillation, and 7% had negative T waves. Twenty percent 20% of the patients had tachycardia. Discussion and Conclusion: According to the cut-off values, '1 point' was assigned when D-dimer was above 24.28 pg/dl, '1 point' was assigned to those with blood pH was 7.3 and below, '1 point' was assigned to those with Nt-proBNP value above 1340 pg/dl, '1 point' was assigned to those with right ventricular dysfunction on ECHO and a new mortality score was calculated for the patients in the high risk group classified with PESI. This score was named as mPESI indicating PESI in malignancy. It was found that the mean overall survival rate of patients with mPESI scores of 2 and below was statistically and significantly higher than of the patients with mPESI scores of 3 and above (p<0.05). It was also found that patients with mPESI scores of 2 and below had 1-month survival rate of 97.3% and 3-months survival rate of 97.3%, On the other hand, the patients with mPESI scores of 3 and above had 1-month survival rate of 33.3% and 3-months survival rate of 16.7%. Keywords: Cancer, Pulmonary thromboembolism, PESI, mPESI, Right heart dysfunction, D-dimer, NT-proBNP, Lactate, Troponin, Blood gase, pH