Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Most pulmonary embolism response teams (PERT) use a radiologist-determined right ventricle to left ventricle ratio (RV:LV) cut-off of 1.0 to risk-stratify pulmonary embolism (PE) patients. Continuous measurements from computed tomography pulmonary angiograms (CTPAs) may improve risk stratification. We assessed associations of CTPA cardiac measurements with acute clinical deterioration and use of advanced PE interventions.

Methods: This was a retrospective study of a PE registry used by eight affiliated emergency departments. We used an artificial intelligence (AI) algorithm to measure RV:LV on anonymized CTPAs from registry patients for whom the PERT was activated (2018–2023) by institutional guidelines. Primary outcome was in-hospital PE-related clinical deterioration defined as cardiac arrest, vasoactive medication use for hypotension, or rescue respiratory interventions. Secondary outcome was advanced intervention use. We used bivariable and multivariable analyses. For the latter, we used least absolute shrinkage and selection operator (LASSO) and random forest (RF) to determine associations of all candidate variables with the primary outcome (clinical deterioration), and the Youden index to determine RV:LV optimal cut-offs for primary outcome.

Results: Artificial intelligence analyzed 1,467 CTPAs, with 88% agreement on RV:LV categorization with radiologist reports (kappa 0.36, 95% confidence interval [CI] 0.28–0.43). Of 1,639 patients, 190 (11.6%) had PE-related clinical deterioration, and 314 (19.2%) had advanced interventions. Mean RV:LV were 1.50 (0.39) vs 1.30 (0.32) for those with and without clinical deterioration and 1.62 (0.33) vs 1.35 (0.32) for those with and without advanced intervention use. The RV:LV cut-off of 1.0 by AI and radiologists had 0.02 and 0.53 P-values for clinical deterioration, respectively. With adjusted LASSO, top clinical deterioration predictors were cardiac arrest at presentation, lowest systolic blood pressure, and intensive care unit admission. The RV:LV measurement was a top 10 predictor of clinical deterioration by RF. Optimal cut-off for RV:LV was 1.54 with odds ratio of 2.50 (1.85, 3.45) and area under the curve 0.6 (0.66, 0.70).

Conclusion: Artifical intelligence-derived RV:LV measurements ≥1.5 on initial CTPA had strong associations with in-hospital clinical deterioration and advanced interventions in a large PERT database. This study points to the potential of capitalizing on immediately available CTPA RV:LV measurements for gauging PE severity and risk stratification.