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01-11-2019 | Phlebothrombosis

A narrative review of red blood cell distribution width as a marker for pulmonary embolism

Authors: Lindsay Hammons, Jason Filopei, David Steiger, Eric Bondarsky

Published in: Journal of Thrombosis and Thrombolysis | Issue 4/2019

Abstract

Red blood cell distribution width (RDW) is a marker of variability in red blood cell size, and is routinely reported as part of a patient’s complete blood count. RDW has been shown to be associated with the prediction, severity and prognosis of pulmonary embolism (PE) in recent studies. The underlying biomolecular mechanism of the relationship of RDW to PE is largely unknown, but is thought to be due to the relationship of RDW with acute inflammatory markers and variations in blood viscosity. This review substantiates that a high RDW level, defined using either an arbitrary number or according to receiver operator curve statistics, is associated with a higher risk of acute PE, increased severity (massive vs. submassive) of PE and increased mortality in patients with PE. Nevertheless, the comparison of current studies is limited due to the definition of high RDW (each study uses a different RDW cutoff level), the broad range of exclusion criteria and the inclusion of differing modalities used to diagnose a PE (computed tomography angiogram, ventilation-perfusion study, or clinical diagnosis). Despite the above limitations, these studies provide a promising future clinical use for RDW as a marker of PE.

The pulmonary embolism severity index (PESI) score is a clinical tool that predicts 30-day mortality in those with a PE based on 11 criteria—age, sex, history of cancer, history of heart failure, history of chronic lung disease, heart rate ≥ 110 beats/min systolic blood pressure < 100 mmHg, respiratory rate ≥ 30, temperature < 96.8 °F/36 °C, altered mental status and oxygen saturation < 90%; the algorithm categorizes patients into five groups corresponding to various prognoses, with the highest-scoring groups having the poorest outcome (30-day mortality up to 24.5%) [36]. The simplified PESI (sPESI) is derived from its predecessor and predicts 30-day mortality, but only uses six criteria—age > 80 years, history of cancer, history of chronic cardiopulmonary disease, heart rate ≥ 110 beats/min, systolic blood pressure 9 < 100 mmHg and arterial oxygen saturation < 90% measured at the time of PE diagnosis; each positive variable is assigned 1 point and the patient is then classified into a low-risk (0 points and 1.1% 30-day mortality rate) or high-risk (≥ 1 point[s] and 8.9% 30-day mortality rate) group[59].

The European Society of Cardiology (ESC) also uses a scoring system (including the sPESI score) to classify PE patients into risk groups based on 30-day mortality risk: low (1 point), intermediate (2 points), intermediate-high (3 points) and high (4 points)[38, 60]. For the ESC classification system, one point is allotted to each of the following risk variables: shock/hypotension (systolic blood pressure < 90 mmHg, or a systolic pressure drop by ≥ 50 mmHg for > 15 min), sPESI ≥ 1, RV dysfunction, and troponin T ≥ 14 pg/mL and/or NT-proBNP > 600 pg/mL [38, 60]. The low risk group has a < 1% 30-day mortality, whereas the high risk group has a > 15% 30-day mortality [38].

The Jen scoring system, published in 2018, also predicts 30-day mortality using high-risk variables to define a binary prediction classification (low vs. high risk). There are eight variables, and they are weighted as follows: age in years, HF (+ 20), lung disease (+ 25), respiratory rate > 30 bpm (+ 40), altered mental status (+ 10), IV required (+ 50), ALT > 75 IU/L (+ 40), and hemoptysis (+ 60). Thirty-day mortality risks were 2.1% and 23% for low (score ≤ 100) and high (> 100) risk patients, respectively (p < 0.001) [61].

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Title: A narrative review of red blood cell distribution width as a marker for pulmonary embolism
Authors: Lindsay Hammons
Jason Filopei
David Steiger
Eric Bondarsky
Publication date: 01-11-2019
Publisher: Springer US
Keyword: Phlebothrombosis
Published in: Journal of Thrombosis and Thrombolysis / Issue 4/2019
Print ISSN: 0929-5305
Electronic ISSN: 1573-742X
DOI: https://doi.org/10.1007/s11239-019-01906-w

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