Does Baseline BUN Have an Additive Effect on the Prediction of Mortality in Patients with Acute Pulmonary Embolism?
Background: In patients with heart failure, elevated levels of blood urea nitrogen (BUN) is a prognostic factor. In this study, we investigated the prognostic value of elevated baseline BUN in short-term mortality among patients with acute pulmonary embolism (PE).
Methods: Between 2007 and 2014, cardiac biomarkers and BUN levels were measured in patients with acute PE. The primary endpoint was 30-day mortality, evaluated based on the baseline BUN (≥14 ng/L) level in 4 groups of patients according to the European Society of Cardiology’s risk stratification (low-risk, intermediate low-risk, intermediate high-risk, and high-risk).
Results: Our study recruited 492 patients with a diagnosis of acute PE (mean age=60.58±16.81 y). The overall 1-month mortality rate was 6.9% (34 patients). Elevated BUN levels were reported in 316 (64.2%) patients. A high simplified pulmonary embolism severity index (sPESI) score (OR: 5.23, 95% CI: 1.43–19.11; P=0.012), thrombolytic or thrombectomy therapy (OR: 2.42, 95% CI: 1.01–5.13; P=0.021), and elevated baseline BUN levels (OR: 1.04, 95% CI: 1.01–1.03; P=0.029) were the independent predictors of 30-day mortality. According to our receiver-operating characteristics analysis for 30-day mortality, a baseline BUN level of greater than 14.8 mg/dL was considered elevated. In the intermediate-low-risk patients, mortality occurred only in those with elevated baseline BUN levels (7.2% vs. 0; P=0.008).
Conclusion: An elevated baseline BUN level in our patients with PE was an independent predictor of short-term mortality, especially among those in the intermediate-risk group.
2. Jenab Y, Alemzadeh-Ansari MJ, Fehri SA, Ghaffari-Marandi N, Jalali A. Effect of delay in hospital presentation on clinical and imaging findings in acute pulmonary thromboembolism. J Emerg Med 2014;46:465-471.
3. Jenab Y, Lotfi-Tokaldany M, Alemzadeh-Ansari MJ, Seyyedi SR, Shirani S, Soudaee M, Ghaffari-Marandi N. Correlates of syncope in patients with acute pulmonary thromboembolism. Clin Appl Thromb Hemost 2015;21:772-776.
4. Stein PD, Kayali F, Olson RE. Estimated case fatality rate of pulmonary embolism, 1979 to 1998. Am J Cardiol 2004;93:1197-1199.
5. Giannitsis E, Katus HA. Biomarkers for clinical decision-making in the management of pulmonary embolism. Clin Chem 2017;63:91-100.
6. Aronson D, Mittleman MA, Burger AJ. Elevated blood urea nitrogen level as a predictor of mortality in patients admitted for decompensated heart failure. Am J Med 2004;116:466-473.
7. Filippatos G, Rossi J, Lloyd-Jones DM, Stough WG, Ouyang J, Shin DD, O'connor C, Adams KF, Orlandi C, Gheorghiade M. Prognostic value of blood urea nitrogen in patients hospitalized with worsening heart failure: insights from the Acute and Chronic Therapeutic Impact of a Vasopressin Antagonist in Chronic Heart Failure (ACTIV in CHF) study. J Card Fail 2007;13:360-364.
8. Miura M, Sakata Y, Nochioka K, Takahashi J, Takada T, Miyata S, Hiramoto T, Inoue K, Tamaki K, Shiba N, Shimokawa H. Prognostic impact of blood urea nitrogen changes during hospitalization in patients with acute heart failure syndrome. Circ J 2013;77:1221-1228.
9. Kazory A. Emergence of blood urea nitrogen as a biomarker of neurohormonal activation in heart failure. Am J Cardiol 2010;106:694-700.
10. Bĕlohlávek J, Dytrych V, Linhart A. Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. Exp Clin Cardiol 2013;18:129-138.
11. Matthews JC, McLaughlin V. Acute right ventricular failure in the setting of acute pulmonary embolism or chronic pulmonary hypertension: a detailed review of the pathophysiology, diagnosis, and management. Curr Cardiol Rev 2008;4:49-59.
12. Coutance G, Cauderlier E, Ehtisham J, Hamon M, Hamon M. The prognostic value of markers of right ventricular dysfunction in pulmonary embolism: a meta-analysis. Crit Care 2011;15:R103.
13. Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JS, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014;35:3033-3069.
14. Jiménez D, Aujesky D, Moores L, Gómez V, Lobo JL, Uresandi F, Otero R, Monreal M, Muriel A, Yusen RD; RIETE Investigators. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010;170:1383-1389.
15. Voelkel MA, Wynne KM, Badesch DB, Groves BM, Voelkel NF. Hyperuricemia in severe pulmonary hypertension. Chest 2000;117:19-24.
16. Nagaya N, Uematsu M, Satoh T, Kyotani S, Sakamaki F, Nakanishi N, Yamagishi M, Kunieda T, Miyatake K. Serum uric acid levels correlate with the severity and the mortality of primary pulmonary hypertension. Am J Respir Crit Care Med 1999;160:487-492.
17. Scherz N, Labarère J, Méan M, Ibrahim SA, Fine MJ, Aujesky D. Prognostic importance of hyponatremia in patients with acute pulmonary embolism. Am J Respir Crit Care Med 2010;182:1178-1183.
18. Yazıcı S, Kırış T, Ceylan US, Akyüz Ş, Uzun AO, Hacı R, Terzi S, Doğan A, Emre A, Yeşilçimen K. The accuracy of combined use of troponin and red cell distribution width in predicting mortality of patients with acute pulmonary embolism. Wien Klin Wochenschr 2016;128(Suppl 8):596-603.
19. Babaoglu E, Hasanoglu HC, Senturk A, Karalezli A, Kilic H, Aykun G, Oztuna D. Importance of biomarkers in risk stratification of pulmonary thromboembolism patients. J Investig Med 2014;62:328-331.
20. Fonarow GC, Adams KF, Jr, Abraham WT, Yancy CW, Boscardin WJ; ADHERE Scientific Advisory Committee, Study Group, and Investigators. Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA 2005;293:572-580.
21. Cauthen CA, Lipinski MJ, Abbate A, Appleton D, Nusca A, Varma A, Goudreau E, Cowley MJ, Vetrovec GW. Relation of blood urea nitrogen to long-term mortality in patients with heart failure. Am J Cardiol 2008;101:1643-1647.
22. Kajimoto K, Minami Y, Sato N, Takano T; Investigators of the Acute Decompensated Heart Failure Syndromes (ATTEND) registry. Serum sodium concentration, blood urea nitrogen, and outcomes in patients hospitalized for acute decompensated heart failure. Int J Cardiol 2016;222:195-201.
23. Tatlisu MA, Kaya A, Keskin M, Avsar S, Bozbay M, Tatlisu K, Eren M. The association of blood urea nitrogen levels with mortality in acute pulmonary embolism. J Crit Care 2017;39:248-253.
|Issue||Vol 15 No 2 (2020): J Teh Univ Heart Ctr|
|Blood urea nitrogen Mortality Pulmonary embolism|
|Rights and permissions|
|This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.|