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To externally validate the prognostic impact of copeptin, either alone or integrated in risk stratification models, in pulmonary embolism (PE), we performed a post hoc analysis of 843 normotensive PE patients prospectively included in three European cohorts.Within the first 30 days, 21 patients (2.5%, 95% CI 1.5-3.8) had an adverse outcome and 12 (1.4%, 95% CI 0.7-2.5) died due to PE. Patients with copeptin ≥24 pmol·L -1 had a 6.3-fold increased risk for an adverse outcome (95% CI 2.6-15.5, p<0.001) and a 7.6-fold increased risk for PE-related death (95% CI 2.3-25.6, p=0.001). Risk classification according to the 2014 European Society of Cardiology (ESC) guideline algorithm identified 248 intermediate-high-risk patients (29.4%) with 5.6% (95% CI 3.1-9.3) at risk of adverse outcomes. A stepwise biomarker-based risk assessment strategy (based on high-sensitivity troponin T, N-terminal pro-brain natriuretic peptide and copeptin) identified 123 intermediate-high-risk patients (14.6%) with 8.9% (95% CI 4.5-15.4) at risk of adverse outcomes. The identification of patients at higher risk was even better when copeptin was measured on top of the 2014 ESC algorithm in intermediate-high-risk patients (adverse outcome OR 11.1, 95% CI 4.6-27.1, p<0.001; and PE-related death OR 13.5, 95% CI 4.2-43.6, p<0.001; highest risk group versus all other risk groups). This identified 85 patients (10.1%) with 12.9% (95% CI 6.6-22.0) at risk of adverse outcomes and 8.2% (95% CI 3.4-16.2) at risk of PE-related deaths.Copeptin improves risk stratification of normotensive PE patients, especially when identifying patients with an increased risk of an adverse outcome., Competing Interests: Conflict of interest: K. Hellenkamp reports grants from BRAHMS GmbH, part of Thermo Fisher Scientific, Hennigsdorf/Berlin, Germany, during the conduct of the study. Conflict of interest: P. Pruszczyk has nothing to disclose. Conflict of interest: D. Jiménez has nothing to disclose. Conflict of interest: A. Wyzgal has nothing to disclose. Conflict of interest: D. Barrios has nothing to disclose. Conflict of interest: M. Ciurzynski has nothing to disclose. Conflict of interest: R. Morillo has nothing to disclose. Conflict of interest: L. Hobohm reports grants from the German Federal Ministry of Education and Research (BMBF 01EO1503), during the conduct of the study. Conflict of interest: K. Keller reports grants from the German Federal Ministry of Education and Research (BMBF 01EO1503), during the conduct of the study. Conflict of interest: K. Kurnicka has nothing to disclose. Conflict of interest: M. Kostrubiec has nothing to disclose. Conflict of interest: R. Wachter reports grants from BRAHMS GmbH, part of Thermo Fisher Scientific, Hennigsdorf/Berlin, Germany, during the conduct of the study; personal fees and other from CVRx; grants, personal fees and other from Boehringer Ingelheim; personal fees and other from Bayer; personal fees and other from Servier; personal fees and other from Novartis; other from Johnson and Johnson; grants from European Union; grants from Bundesministerium für Bildung und Forschung; personal fees from Pfizer; and personal fees and other from Medtronic, outside the submitted work. Conflict of interest: G. Hasenfuß reports grants from BRAHMS GmbH, part of Thermo Fisher Scientific, Hennigsdorf/Berlin, Germany, during the conduct of the study; other from Servier, other from Impulse Dynamics, other from Novartis, other from AstraZeneca, other from Corvia, and other from Vifor Pharma, outside the submitted work. Conflict of interest: S. Konstantinides reports grants and personal fees from Bayer HealthCare, grants and personal fees from Boehringer Ingelheim, grants and personal fees from Actelion, grants from Daiichi Sankyo, grants and personal fees from Pfizer-Bristol-Myers Squibb, and personal fees from MSD, outside the submitted work. Conflict of interest: M. Lankeit reports grants from German Federal Ministry of Education and Research (BMBF 01EO1503) and grants from BRAHMS GmbH, part of Thermo Fisher Scientific, Hennigsdorf/Berlin, Germany, during the conduct of the study; personal fees from Actelion, personal fees from Bayer, personal fees from Daiichi Sankyo, personal fees from MSD, and personal fees from Pfizer-Bristol-Myers Squibb, outside the submitted work., (Copyright ©ERS 2018.)

Our aim was the assessment of the prognostic significance of right heart thrombi (RiHT) and their characteristics in pulmonary embolism in relation to established prognostic factors.138 patients (69 females) aged (mean±sd) 62±19 years with RiHT were included into a multicenter registry. A control group of 276 patients without RiHT was created by propensity scoring from a cohort of 963 contemporary patients. The primary end-point was 30-day pulmonary embolism-related mortality; the secondary end-point included 30-day all-cause mortality. In RiHT patients, pulmonary embolism mortality was higher in 31 patients with systolic blood pressure <90 mmHg than in 107 normotensives (42% versus 12%, p=0.0002) and was higher in the 83 normotensives with right ventricular dysfunction (RVD) than in the 24 normotensives without RVD (16% versus 0%, p=0.038). In multivariable analysis the simplified Pulmonary Embolism Severity Index predicted mortality (hazard ratio 2.43, 95% CI 1.58-3.73; p<0.0001), while RiHT characteristics did not. Patients with RiHT had higher pulmonary embolism mortality than controls (19% versus 8%, p=0.003), especially normotensive patients with RVD (16% versus 7%, p=0.02).30-day mortality in patients with RiHT is related to haemodynamic consequences of pulmonary embolism and not to RiHT characteristics. However, patients with RiHT and pulmonary embolism resulting in RVD seem to have worse prognosis than propensity score-matched controls., (Copyright ©ERS 2016.)

High-sensitivity troponin T (hsTnT) helps in identifying pulmonary embolism patients at low risk of an adverse outcome. In 682 normotensive pulmonary embolism patients we investigate whether an optimised hsTnT cut-off value and adjustment for age improve the identification of patients at elevated risk. Overall, 25 (3.7%) patients had an adverse 30-day outcome. The established hsTnT cut-off value of 14 pg·mL(-1) retained its high prognostic value (OR (95% CI) 16.64 (2.24-123.74); p=0.006) compared with the cut-off value of 33 pg·mL(-1) calculated by receiver operating characteristic analysis (7.14 (2.64-19.26); p<0.001). In elderly (aged ≥75 years) patients, an age-optimised hsTnT cut-off value of 45 pg·mL(-1) but not the established cut-off value of 14 pg·mL(-1) predicted an adverse outcome. An age-adjusted hsTnT cut-off value (≥14 pg·mL(-1) for patients aged <75 years and ≥45 pg·mL(-1) for patients aged ≥75 years) provided additive and independent prognostic information on top of the simplified pulmonary embolism severity index (sPESI) and echocardiography (OR 4.56 (1.30-16.01); p=0.018, C-index=0.77). A three-step approach based on the sPESI, hsTnT and echocardiography identified 16.6% of all patients as being at higher risk (12.4% adverse outcome). Risk assessment of normotensive pulmonary embolism patients was improved by the introduction of an age-adjusted hsTnT cut-off value. A three-step approach helped identify patients at higher risk of an adverse outcome who might benefit from advanced therapy., (Copyright ©ERS 2015.)