Reply to the Letter to the Editor‘‘Contrast-enhanced multidetectorcomputed tomography: A newprognosticator in acute pulmonaryembolism?’’

Re Po Ca diol. 2013;32(10):841---842 Re is a Po uguesa de Ca diologia Po uguese Jou nal o Ca diology www. e po ca diol.o g LETTER TO THE EDITOR Reply o he Le e o he Edi o ‘‘Con as -enhanced mul ide ec o compu ed omog aphy: A new p ognos ica o in acu e pulmona y embolism?’’ Respos a à Ca a ao Edi o «Angiog afia pulmona po omog afia compu ado izada: uma no a e amen a p ognós ica na omboembolia pulmona aguda?» We a e g a e ul o D s Ba a, P o idência and Pai a o hei commen s on ou pape .1They sugges ha we canno exclude ha he associa ion be ween RV/LV a io and mo ali y is due o chance and hypo hesize ha o he pa ame e s could be p edic i e o p ognosis in a la ge coho . We should emphasize ha in con as o mos epo s on he p ognos ic alue o MCDT, which usually include unselec ed popula ions o low- o in e media e- isk PE (mean RV/LV a io <1.5), we ha e s udied a e y specific popula ion, eflec ed by he ele a ed mean RV/LV a io (>1.6). This ac had an impac on he coho size, leading o a low s a is ical powe . Howe e , e en in such a small coho , and in con as o e e y o he MCDT-de i ed index, such as obs uc ion bu den (as ei he a con inuous o a dicho omous a iable), he RV/LV a io eme ged as he only one ha was significan ly di e en be ween he wo g oups. We belie e ha ou esul s eflec a eal di e ence, al hough om a s a is ical poin o iew we canno exclude a chance associa ion: howe e , we can es ima e ha p obabili y o be unde 5%. Ou esul s a e also in line wi h o he obse a- ions, such as hose in a ecen pape by Beca ini e al. wi h mo e han 450 pa ien s demons a ing ha a RV/LV a io <0.9 has a 100% nega i e p edic i e alue o dea h due o PE and is an independen p edic o o mo ali y.2Las ly, he RV/LV a io co ela ed wi h o he su oga e ma ke s o wo se p ognosis. Un o una ely, we canno specula e whe he o he a iables could ha e been p edic i e o p ognosis in a la ge coho wi h simila clinical p ofile. DOI o o iginal a icle: h p://dx.doi.o g/10.1016/j. epc.2013.01.010 Addi ionally, D Ba a e al. s a e ha ou s udy does no say whe he MDCT can add p ognos ic alue o cu en ly a ailable clinical isk sco es (CRS). I should be ecalled ha he aim o ou wo k was o compa e adiological pa ame e s in e ms o hei abili y o p edic long- e m mo ali y and no o analyze hei addi ional alue o cu en clini- cal s a ifica ion sys ems. Al hough e idence is g owing ega ding he ole o CRS in he iden ifica ion o lowe - isk pa ien s who can be sa ely discha ged home,3 hei p ogno- s ic alue o in e media e- and high- isk PE is unknown.4 Mo eo e , none o he a ailable p ospec i ely alida ed CRS include in o ma ion om a key p ognos ic de e minan , igh en icula unc ion,4and nei he PESI no sPESI we e specifically s udied ega ding he decision whe he o p oceed o h ombolysis. A ecen scien ific s a emen om he Ame ican Hea Associa ion on he managemen o massi e and submassi e PE con inues o suppo he use o clinical signs o impending shock/ espi a o y dis ess and e idence o RV impai men /inju y o he selec ion o pa ien s sui able o h ombolysis.5The use ulness o a CRS e sus an isola ed isk ma ke will always be dependen on a balance be ween inc emen al p ognos ic alue e sus simplici y and consequen clinical applica ion in e e yday clinical p ac ice.4Mo eo e , he pe o mance o a CRS may be di e en depending on whe he he aim is o iden i y low- isk PE pa ien s ha can be sa ely discha ged home o o selec high- isk pa ien s o h ombolysis. Al hough e idence is al eady a ailable o he o me , he ques ion whe he he combina ion o a CRS wi h imaging o labo a o y pa ame e s is be e han each one alone o selec ing pa ien s o h ombolysis emains o be answe ed. In he ecen ly p esen ed mul icen e PEITHO ial, pa ien s wi h he simul aneous p esence o RV dys unc ion (in a ound hal o pa ien s using MDCT) and a posi i e oponin es we e andomized o enec eplase o placebo (pe sonal communica ion, S Kons an inides, Ame ican College o Ca diology, 2013). Se en-day all-cause mo ali y in his in e media e- isk popula ion was less han 2% in bo h a ms, lowe han ha epo ed in he MAPPET-3 ial, in which pa ien s we e selec ed based only on RV dys unc ion.6 D Ba a e al. also sugges he use o mul i a ia e anal- ysis o assess he independen alue o RV/LV a io o p ognos ica ion. Al hough we do no ques ion he use ul- ness o such me hodology, we delibe a ely chose no o pe o m i , since he minimum numbe o e en s pe a i- able needed is a leas fi e o nine, and p e e ably g ea e 0870-2551/$ – see on ma e © 2013 Sociedade Po uguesa de Ca diologia Published by Else ie España, S.L. All igh s ese ed. h p://dx.doi.o g/10.1016/j. epc.2013.02.014 842 LETTER TO THE EDITOR han 10.7The e o e, he fi e e en s eco ded migh yield an insu moun able bias. Howe e , we conside ha he no el demons a ion ha he RV/LV a io is also associa ed wi h mo ali y in a specific g oup o PE pa ien s wi h a se e ely comp omised RV is o clinical in e es . Conflic s o in e es The au ho s ha e no conflic s o in e es o decla e. Re e ences 1. Bap is a R, San iago I, Jo ge E, e al. One-sho diagnos ic and p o- gnos ic assessmen in in e media e- o high- isk acu e pulmona y embolism: he ole o mul ide ec o compu ed omog aphy. Re Po Ca diol. 2013;32:7---13. 2. Beca ini C, Agnelli G, Vedo a i MC, e al. Mul ide ec o com- pu ed omog aphy o acu e pulmona y embolism: diagnosis and isk s a ifica ion in a single es . Eu Hea J. 2011;32:1657---63. 3. Lankei M, Gómez V, Wagne C, e al. A s a egy combining imag- ing and labo a o y bioma ke s in compa ison wi h a simplified clinical sco e o isk s a ifica ion o pa ien s wi h acu e pul- mona y embolism. Ches . 2012;141:916---22. 4. Kons an inides S, Goldhabe SZ. Pulmona y embolism: isk assess- men and managemen . Eu Hea J. 2012;33:3014---22. 5. Ja MR, McMu y MS, A che SL, e al. Managemen o massi e and submassi e pulmona y embolism, ilio emo al deep ein h ombosis, and ch onic h omboembolic pulmona y hype ension: a scien ific s a emen om he Ame ican Hea Associa ion. Ci cula ion. 2011;123:1788---830. 6. Single-bolus enec eplase plus hepa in compa ed wi h hepa in alone o no mo ensi e pa ien s wi h acu e pulmona y embolism who ha e e idence o igh en icula dys unc ion and myoca - dial inju y: a ionale and design o he Pulmona y Embolism Th ombolysi. Am Hea J. 2012;163, 33---38.e1. 7. Moons KGM, Roys on P, Ve gouwe Y, e al. P ognosis and p ogno- s ic esea ch: wha , why, and how? BMJ (Clinical esea ch ed). 2009;338:b375. Rui Bap is aa,c,∗, Rogé io Teixei ab,c, Elisabe e Jo gea,c, Ped o Mon ei oa,c aSe ic¸o de Ca diologia, Hospi ais da Uni e sidade de Coimb a, Cen o Hospi ala e Uni e si á io de Coimb a, Coimb a, Po ugal bSe ic¸o de Ca diologia, Hospi al Bea iz Ângelo, Lou es, Po ugal cFaculdade de Medicina, Uni e sidade de Coimb a, Coimb a, Po ugal ∗Co esponding au ho . E-mail add ess: [email p o ec ed] (R. Bap is a).