Red Cell Distribution Width–Standard Deviation to Albumin Ratio and Mortality in Acute Pulmonary Thromboembolism: A Single-Center Retrospective Cohort Study

Red Cell Distribution Width–Standard Deviation to Albumin Ratio and Mortality in Acute Pulmonary Thromboembolism: A Single-Center Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Red Cell Distribution Width–Standard Deviation to Albumin Ratio and Mortality in Acute Pulmonary Thromboembolism: A Single-Center Retrospective Cohort Study Funda Başyiğit, Emine Cansu Yücel, Oğuz Uçar, Nazlı Turan, Belma Yaman, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6536117/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in Thrombosis Journal → Version 1 posted 7 You are reading this latest preprint version Abstract Background Recent studies have shown a relation between red blood cell distribution width (RDW) / albumin (RAR) levels and worse outcomes in cases of pulmonary embolism (PE). Simplified pulmonary embolism severity index (sPESI) has been developed from more complex PESI score, predicting the risk of death in patients with acute PE (APE). This study aims to investigate whether RDW-Standard Deviation/Albumin (RDW-SD/Alb) can serve as a useful prognostic marker for APE and enhance the predictive capability of the sPESI. Methods This research is a single-center, retrospective analysis involving patients over 18 years. We enrolled 235 consecutive hospitalized patients with confirmed APE diagnoses. To evaluate the sensitivity and specificity of RDW-SD/Alb, sPESI, and the combined sPESI plus RDW-SD/Alb in predicting 6-month all-cause death, we used Receiver Operating Characteristic (ROC) curves. Additionally, we conducted Kaplan-Meier analysis to assess the impact of elevated RDW-SD/Alb levels (> 13.6) on patient survival time. We utilized multivariate Cox regression analysis to identify independent prognostic factors affecting patients survival. Results The mortality rate for RDW-SD/Alb > 13.6 group was significantly higher than that for the RDW-SD/Alb ≤ 13.6 group. Area under ROC (AUROC) of sPESI plus RDW-SD/Alb was statistically larger than AUROC of sPESI ( p = 0.025). In the fully adjusted model, increased RDW-SD/Alb levels were consistently linked to all-cause mortality within six months of admission. Conclusions The predictive value of the sPESI for 6-month all-cause death improved when the RDW-SD/Alb > 13.6 parameter was included. RDW-SD/Alb > 13.6, a novel inflammatory marker, was an independent prognostic factor for survival in patients with APE. Pulmonary embolism Red cell distribution width Albumin Venous Thrombosis sPESI Score Figures Figure 1 Figure 2 INTRODUCTION Pulmonary embolism (PE) denotes obstruction of the pulmonary artery and can be induced by many origins, including tumors, fat, air, amniotic fluid, and septic emboli, though the extended majority are thromboembolic. 1 After ischemic heart disease and stroke, PE is the third foremost cause of cardiovascular mortality worldwide. 2 Red blood cell distribution width (RDW) is a parameter routinely reported in the complete blood count (CBC) test, indicating the variability in the size of red blood cells in peripheral blood, and it is traditionally utilized clinically for the differential diagnosis of anemias. Recent evidence confirms that anisocytosis is common in human disorders such as cancer, liver failure, diabetes, cardiovascular disease, venous thromboembolism, community-acquired pneumonia, chronic obstructive pulmonary disease, kidney failure, and other acute or chronic conditions. Furthermore, the value of RDW is now believed to be a decisive and independent risk factor for death in the general population. 3 Serum albumin is a protein produced by the liver that serves as a negative acute phase reactant, meaning its levels decrease in response to inflammation. 4 This protein plays several important roles, including acting as an anti-inflammatory agent, antioxidant, anticoagulant, and preventing platelet aggregation. 5 RDW/Albumin (RAR) is a novel inflammatory biomarker that has been linked to mortality in various diseases, including chronic obstructive pulmonary disease, myocardial infarction, diabetic ketoacidosis, acute respiratory distress syndrome, and PE. 6 , 7 The simplified pulmonary embolism severity index (sPESI) has been developed from the more complex PESI score, which predicts the risk of death in patients with acute PE (APE) using only clinical indices. 8 Although nearly 20% of patients receiving treatment for PE die within 90 days, PE is not typically the direct cause of death; rather, it often occurs alongside other serious conditions such as cancer, sepsis, or illnesses that necessitate hospitalization. 9 Therefore, incorporating RAR into the sPESI score may enhance its prognostic value. So far, only two studies have investigated the prognostic value of RAR in acute pulmonary embolism (APE). 6 , 7 Our goal is to determine whether RDW-Standard deviation/Albumin (RDW-SD/Alb) can serve as a valuable prognostic marker in APE and whether it can improve the prognostic power of the sPESI score. METHODS This study is a single-center, retrospective analysis implicating patients 18 years of age or older. A total of 235 consecutive patients who were hospitalized with a confirmed diagnosis of APE and were consulted to the cardiology department from the emergency department between February 2023 and March 2024 were screened. These patients were followed until October 2024. Patients were excluded if they had end-stage liver disease, a glomerular filtration rate (GFR) of less than 15 mL/min, a left ventricular ejection fraction of less than 30%, severe valvular heart disease, or congenital heart disease. Ultimately, we included 184 survivor patients and 51 non-survivor patients [male 46.2%, median age 66,0 (23.0) years; 49.0% male, median age 74,0 (18.0) years]. Blood samples were collected upon admission, and CBCs were performed using the Sysmex XT 4000i machine for each patient. The ratio of RDW-SD to albumin was calculated by dividing the RDW-SD (fL) by the albumin level (g/dL). We gathered the clinical history, laboratory test results, transthoracic echocardiography (TTE) findings, and pulmonary computed tomographic angiography (CTA) results from the electronic medical reports in our hospital. All laboratory tests, TTE examinations, and CTA results for the patients were obtained within 24 hours of their admission to the emergency department. The sPESI score was calculated for each patient by the two different cardiologists. The score included variables such as age, history of cancer, chronic pulmonary disease, heart rate, systolic blood pressure (SBP), and oxygen saturation. 1 point is assigned for each of these situations; age is over 80 years, heart rate ≥ 110 beats/minute, SBP < 100 mmHg, or arterial oxygen saturation < 90%. Statistical Analysis We examined all the data using SPSS version 22.0 software (SPSS Inc., Chicago, IL). Continuous data were delivered as either mean ± standard deviation for parametric data or median ± interquartile range for nonparametric data. Parametric continuous variables were assessed using the Independent Samples T-test, while nonparametric continuous variables were evaluated using the Mann-Whitney U test. We compared categorical data using Pearson's Chi-square test. The area under the receiver operating characteristic (ROC) curve was analyzed using the MedCalc program (MedCalc Software Ltd). The DeLong test compared the area under the ROC curves (AUROC). For patients with RDW-SD/Alb levels greater than 13.6, we assigned 1 point; otherwise, 0 points were counted for the sPESI score, resulting in a new score referred to as sPESI plus RDW-SD/Alb. We used ROC curves to determine the sensitivity and specificity of RDW-SD/Alb, sPESI, and the sPESI plus RDW-SD/Alb score in predicting 6-month all-cause death and compared the AUROC of both the sPESI and the sPESI plus RDW-SD/Alb score. We performed Kaplan-Meier analysis to evaluate the impact of higher RDW-SD/Alb levels (> 13.6) on patient survival time. We selected variables with a P -value of less than 0.05 in the univariate Cox regression analysis for multivariate Cox regression analysis. Multivariate Cox regression analysis was utilized to specify the effect of independent prognostic factors on patient survival. Four different models were used: one unadjusted model and three adjusted models with increasing numbers of adjusted factors. The outcomes were evaluated at a 95% confidence interval, with significance considered at p < 0.05. RESULTS We analyzed 235 consecutive patients diagnosed with APE, as revealed by pulmonary CTA, and separated them into the survivor group (n = 184, 46.2% male, mean age = 66.0 ± 23.0 years) and non-survivor group ( n = 51, 49.0% male, mean age = 74.0 ± 18.0 years). Table 1 outlines the demographic and clinical data, while Table 2 provides the laboratory parameters for survivors and non-survivors. Hypertension (60.8% vs . 45.1%, p = 0.047), diabetes (35.3% vs . 21.7%, p = 0.047), and chronic obstructive pulmonary disease (27.5% vs . 14.7%, p = 0.033) were more prevalent in non-survivor group than survivor group. The neutrophil (7.83 ± 5.92 vs . 6.64 ± 4.85, p = 0.043), hs-troponin (48.7 ± 41.2 vs . 31.2 ± 44.3, p = 0.007), NT-Pro-Brain natriuretic peptide (NT-Pro-BNP) (2902 ± 2448 vs . 1802 ± 2609, p = 0.004), C-reactive protein (CRP) (68.5 ± 100.5 vs . 45.9 ± 63.5, p = 0.006) and RDW-SD/Alb (14.9 ± 6.8 vs . 12.5 ± 3.8, p = 0.006) were higher in non-survivor group than survivor group, while lymphocyte (0.98 ± 1.10 vs . 1.68 ± 1.23, p < 0.001) was lower. Table 1 Baseline Patient Characteristics of Participants, Survivors and Non-Survivors Characteristics Survivor N = 184 Non-Survivor N = 51 P Value Age, year 66.0 ± 23.0 74.0 ± 18.0 < .001 Gender, male, n (%) 85 (46,2) 25 (49.0) 0.721 HT, n (%) 83 (45.1) 31 (60.8) 0.047 DM, n (%) 40 (21.7) 18 (35.3) 0.047 COPD, n (%) 27 (14.7) 14 (27.5) 0.033 CVD, n (%) 15 (8.2) 8 (15.7) 0.109 DVT, n (%) 59 (32.1) 19 (37.3) 0.486 Dyspnea 145 (78.8) 44 (86.3) 0.234 Hemoptysis 22 (12.0) 6 (11.8) 0.970 Chest pain 83 (45.1) 11 (21.6) 0.002 Syncope 15 (8.2) 3 (5.9) 0.590 SBP, mmHg 120.0 ± 28.3 120 ± 32.0 0.756 Heart Rate 88.0 ± 27.5 96.0 ± 26.0 0.014 Arterial Saturation, % 90.6 ± 6.9 90.0 ± 5.0 0.002 Pulmoner Emboli Severity*, n (%) Low 33 (17.9) 0 (0) < 0.001 Intermediate 136 (73.9) 44 (86.3) High 15 (8.2) 7 (13.7) sPESI 1.0 ± 2.0 2.0 ± 2.0 < .001 COPD, chronic obstructive pulmonary disease; CVD, cerebrovascular disease; DM, diabetes mellitus; DVT, deep vein thrombosis; HT, hypertension;SBP, systolic blood pressure; sPESI, simplified pulmonary embolism severity index; Pulmoner Emboli Severity* 8 Table 2 Laboratory Parameters of Survivors and Non-Survivors Survivor N = 184 Non-Survivor N = 51 P Value Creatinine, mg/dl 0.90 ± 0.30 0.84 ± 0.44 0.790 Sodyum, mmol/l 138 ± 4.0 137 ± 6 0.011 Laktat, mmol/l 1.82 ± 0.96 2.10 ± 1.23 0.027 AST, u/l 21.0 ± 11.5 25.0 ± 29.0 0.006 RBC, 10^ 6 /ul 4.5 ± 1.0 4.4 ± 1.4 0.340 Hb, g/dl 12.7 ± 3.1 12.0 ± 3.3 0.106 Hematocrit, % 39.7 ± 8.8 37.6 ± 11.6 0.321 MCV, fL 88.5 ± 9.6 88.1 ± 9.4 0.977 MCH, pg 28.5 ± 3.8 27.6 ± 3.8 0.275 Platelet, 10^3/uL 258.0 ± 70.7 239.0 ± 11.2 0.046 WBC, 10^3/uL 9.38 ± 5.05 9.97 ± 6.07 0.380 Neutrophil, 10^ 3 /uL 6.64 ± 4.85 7.83 ± 5.92 0.043 Lymphocyte, 10^ 3 /uL 1.68 ± 1.23 0.98 ± 1.10 < .001 hs-Troponin T, ng/L 31.2 ± 44.3 48.7 ± 41.2 0.007 NT-ProBNP, pg/mL 1802 ± 2609 2902 ± 2448 0.004 D-Dimer, µg/mL 5.43 ± 2.90 5.43 ± 3.80 0.112 CRP, mg/L 45.9 ± 63.5 68.5 ± 100.5 0.006 RDW-SD, fL 45.5 ± 6.8 50.8 ± 9.8 < .001 Albumin, g/dL 3.56 ± 0.49 3.47 ± 0.80 < .001 RDW-SD/Alb, fL.dL/g 12.5 ± 3.8 14.9 ± 6.8 < .001 AST, aspartate aminotransferase; BNP, brain natriuretic peptide; CRP, C reactive protein; Hb, hemoglobin; MCH, mean corpuscular hemoglobin; MCV, mean corpuscular volume; RAR, red cell distribution-standard deviation/albumin width ratio; RBC, red blood cell; RDW-SD, red cell distribution-standard deviation; WBC, white blood cell The cut-off value of RDW-SD/Alb for 6-month all-cause death was 13.6. RDW-SD/Alb higher than 13.6 predicted the 6-month all-cause death with a sensitivity of 70.6% and specificity of 67.0% ( p < 0.001). AUROC values for the variables analyzed by ROC curve analysis in terms of predicting 6-month all-cause death in APE were as follows: RDW-SD/Alb: AUC: 0.727 (95% CI: 0.666–0.784, p < 0.001), sPESI: AUC: 0.708 (95% CI: 0.645–0.765, p < 0.001), sPESI plus RDW-SD/Alb score: AUC: 0.740 (95% CI: 0.679–0.795, p < 0.001). After the pairwise comparison by the Delong test, AUROC of sPESI plus RDW-SD/Alb score was statistically larger than the AUROC of sPESI ( p = 0.025) (Fig. 1 ). We generated Kaplan–Meier survival curves for patients (Fig. 2 ). The mortality rate in the RDW-SD/Alb > 13.6 group was significantly greater compared to the RDW-SD/Alb ≤ 13.6 group (Log-rank, p 13.6 group was definitively associated with all-cause mortality within a six-month period following admission. We have installed three adjustment models (Table 3 ). In Model 1, adjusted for age and diabetes, and Model 2, adjusted for age, diabetes, heart rate, and arterial oxygen saturation (ASAT), we observed a statistically remarkable increase in the risk of all-cause mortality within 6 months after hospital admission for patients with RDW-SD/Alb > 13.6. Compared to the lower RDW-SD/Alb group (≤ 13.6), patients in the higher RDW-SD/Alb group (> 13.6) showed elevated 6-month all-cause mortality (OR 2.755, 95% CI 1.420, 5.345, p = 0.003) in the Model 3, adjusted for age, diabetes, heart rate, ASAT, aspartate aminotransferase (AST), troponin, CRP, and the sPESI score. Other independent prognostic factors on survival in the Model 3 were age and AST (HR 1.030, 95% CI 1.005, 1.056, p = 0.018; HR 1.020, 95% CI 1.008, 1.032, p = 0.003, respectively). Furthermore, there was a statistically significant difference between Model 1 and Model 2, but no significant difference between Model 2 and Model 3 (p < 0.001; p = 0.076, respectively). Table 3 Hazard ratios (HRs) for 6-month mortality based on RDW-SD/Alb in acute pulmonary embolism Crude Model Model I Model II Model III HR(95%CI) P HR(95%CI) P HR(95%CI) P HR(95%CI) P 6-month all cause mortality RAR ≤ 13.6 Ref Ref Ref Ref RAR > 13.6 4.081 (2.152–7.739) < .001 3.369 (1.765–6.430) < .001 3.229 (1.696–6.149) < .001 2.755 (1.420–5.345) 0.003 Crude model: we did not adjust other covariants. Model I: we adjusted age and diabetes. Model II: we adjusted age, diabetes, heart rate and ASAT. Model III: we adjusted age, diabetes, heart rate and ASAT, AST, troponin, CRP and sPESI score. ASAT = arterial saturation, AST = aspartate aminotransferase, CI = confidence interval, CRP = C-reactive protein, Cre = creatinine, HR = hazard ratio, RDW-SD/Alb = red blood cell distribution width-standard deviation to albumin ratio, Ref = reference, sPESI: simplified pulmonary embolism severity index. DISCUSSION The results of our study identified three main findings: First, the RDW-SD/Alb ratio was higher in the non-survivor group than in the survivor group among patients with APE. Second, the cut-off value RDW-SD/Alb for the predicting 6-month all-cause mortality was determined to be 13.6. Third, an RDW-SD/Alb greater than 13.6 was associated with an expanded risk of 6-month all-cause mortality. Additionally, the predictive value of the sPESI score for 6-month all-cause death improved when the RDW-SD/Alb > 13.6 parameter was included. Finally, RDW-SD/Alb levels greater than 13.6, along with age and AST, were independent prognostic factors for survival in patients with APE. The relationship between RDW and venous thromboembolism is complex and is still under investigation. It is well established that various nutritional deficiencies can occur in patients who experience chronic immobilization and declining renal function, both of which are common in individuals with deep vein thrombosis (DVT) and PE. Additionally, hypoxia caused by the obstruction of pulmonary arteries may lead to the hyperactivation of adrenergic and neurohormonal pathways, triggering the release of pro-inflammatory cytokines. Salvano et al. observed that RDW may be elevated due to the intricate interactions among these underlying conditions in patients with APE. 3 Albumin is a medium-sized protein synthesized by the liver and plays a key role in supporting colloid osmotic pressure in the body. Like RDW, albumin is important for the inflammatory response and oxidative stress. 10 Numerous studies have indicated that low levels of albumin are related to poor prognosis in patients with APE. 6 In this study, the combination of RDW-SD and albumin, referred to as RDW-SD/Alb, was linked to all-cause mortality in patients with APE, even after adjusting for various other factors. APE is classified into three categories based on imaging findings and patient characteristics: high-risk, intermediate-risk, and low-risk. High-risk PE is defined by sustained hypotension, indicated by a SBP of less than 90 mm Hg for at least 15 minutes or a vasopressor requirement with no other plausible explanation for the shock. Intermediate-risk PE includes patients who exhibit signs of right ventricular (RV) dysfunction through imaging or biomarker evidence (such as myocardial necrosis or chamber dilation) but do not show sustained hypotension. A subcategory of intermediate-risk, intermediate-high-risk PE involves patients with both imaging and biomarker evidence of RV dysfunction. Low-risk PE does not fulfill the criteria for high-risk or intermediate-risk PE. 8 Severe PE patients with SBP greater than 90 mm Hg are categorized according to their risk of hemodynamic collapse and death. Individual risk factor-based clinical prediction scores can be used to identify patient subgroups at high risk for hemodynamic instability. Despite the large number of published clinical prediction scores, only a few numbers have been prospectively validated and shown to be trustworthy. 11 These include the Bova score, the PESI, and sPESI scores. The Bova score combines high troponin levels and RV dysfunction with hemodynamic instability criteria, whereas the PESI and sPESI scores combine markers of cardiopulmonary impairment with age and comorbidities. 12 , 13 The European Society of Cardiology guidelines recommend using PESI, an algorithm that calculates various clinical and hemodynamic indicators, to predict 30-day mortality. Due to the complexity of the original PESI, which consists of 11 differently weighted variables, a simplified version called sPESI has been developed and validated. A sPESI score of 0 identifies a low-risk group, with an approximately 1.0% mortality risk within 30 days. In contrast, a sPESI score of 1 or higher identifies a high-risk group, with a 30-day mortality risk increasing to 10.9%. 14 Additionally, markers of RV dysfunction, including ECG, TTE, BNP, and troponin levels, are commonly used for prognostic evaluation in patients with APE. According to retrospective investigations, scoring systems that use biomarkers like the BOVA score are better than the sPESI score at predicting the likelihood of unfavorable events in the early stages. 15 – 18 Although the sPESI score is a powerful tool for excluding adverse events in patients with a score of 0, its predictive power for mortality in patients with a score of ≥ 1 is still in doubt. Trimaille et al. examined whether the sPESI score's capacity to predict death was enhanced by including renal dysfunction. 19 The findings demonstrated that a group with extremely high mortality was found when renal failure was included as a biomarker to the sPESI score. This implies that more biomarkers are required to help the sPESI score more accurately predict the likelihood of unfavorable outcomes. In the present study, although the sPESI score was higher in the non-survivor group, both groups had high-risk sPESI scores. In light of these findings, RDW-SD/Alb might be thought of as a predictor of all-cause mortality among patients with high-risk features. Furthermore, we observed that the predictive value of the sPESI score for six-month all-cause death improved when RDW-SD/Alb > 13.6 was included as a parameter. Therefore, in addition to the sPESI score, RDW-SD/Alb can be utilized as a biomarker to predict early mortality in individuals with APE more precisely. Recently, Ding et al. examined the relationship between RAR levels and the risk of all-cause mortality in patients with APE admitted to the intensive care unit (ICU). The researchers categorized the patients into three groups according to their RAR levels: Low RAR (2.68–4.71), Middle RAR (4.71–6.09), and High RAR (6.09–15.45). The study found a significant association between the Middle and High RAR groups and an increased risk of all-cause mortality in patients with PE. 6 Furthermore, our study indicated that higher RDW-SD/Alb (> 13.6) was associated with 6-month all-cause mortality, not only in ICU patients diagnosed with APE but also in all hospitalized patients with this condition. Eraslan et al. evaluated the impact of RAR on mortality in patients with PE. 7 Their analysis identified a cut-off value of 5.294 using ROC analysis. Patients with an RAR of 5.294 or higher had a significantly shorter mean survival time compared to those with an RAR below this threshold. In our study, we established that the RDW-SD/Alb cut-off value predicting all-cause death at six months was 13.6. It is important to note that Eraslan et al. calculated the RAR using the RDW-CV (%) unit, whereas we utilized the RDW-SD (fL) unit. We believe the differing cut-off values between the two studies may be attributed to this distinction. Recent studies indicated that RDW-SD may offer additional diagnostic value, as it is a direct measurement that is not influenced by mean corpuscular volume and more accurately reflects variations in red cell size. 20 , 21 There is insufficient data in the literature about whether RDW-SD or RDW-CV should be used for calculating RAR. Our study has several limitations. First, it was a single-center, retrospective, observational study, which inherently has limitations due to its design. Second, data on the study population were obtained from our hospital's electronic medical records, which may introduce a selective bias. Third, RDW-SD/Alb is a recently identified inflammatory marker, and a prospective study is necessary to more accurately determine its predictive cut-off value in patients with APE. CONCLUSION Our study has identified RDW-SD/Alb as a new independent inflammatory marker that can predict 6-month all-cause mortality in patients with APE. This marker is low-cost and easy to use, providing valuable early information. As a novel parameter, RDW-SD/Alb may improve the management of APE patients by aiding in the prediction of 6-month mortality risk. It may be advisable to closely monitor APE patients with an RDW/Alb > 13.6. Abbreviations APE Acute pulmonary emolism ASAT Arterial oxygen saturation AST Aspartate aminotransferase CBC Complete blood count CRP C-reactive protein CTA Computed tomographic angiography DVT Deep vein thrombosis GFR Glomerular filtration rate NT-Pro-BNP NT-Pro-Brain natriuretic peptide PE Pulmonary embolism RAR Red blood cell distribution width (RDW) / Albumin RDW Red blood cell distribution width RDW-SD/Alb RDW-Standard Deviation/Albumin ROC Receiver operating characteristic sPESI Simplified pulmonary embolism severity index TTE Transthoracic echocardiography Declarations Ethics approval and consent to participate Our study protocol has been approved by the ethics committee at our center and was implemented per the principles of the Declaration of Helsinki. We did not obtain informed consent because the study was designed retrospectively. Consent for publication Not applicable. Availability of data and materials The data supporting the findings of this study are available on request from the corresponding author and with permission from our hospital. Competing interests The authors declare no competing interests. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Authors' contributions FB: Conceptualization, Formal Analysis, Methodology, Project administration, Validation, Visualization, Writing – review & editing. ECY: Investigation, Validation, Visualization. OU: Formal Analysis, Investigation, Project administration. NT: Validation, Visualization, Writing – original draft. BY: Writing – review & editing. ANA: Methodology, Project administration. MMA: Methodology, Project administration. HT: Visualization, Writing – review & editing. 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Cite Share Download PDF Status: Published Journal Publication published 01 Jul, 2025 Read the published version in Thrombosis Journal → Version 1 posted Editorial decision: Revision requested 20 May, 2025 Reviews received at journal 12 May, 2025 Reviewers agreed at journal 30 Apr, 2025 Reviewers invited by journal 29 Apr, 2025 Editor assigned by journal 28 Apr, 2025 Submission checks completed at journal 28 Apr, 2025 First submitted to journal 26 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6536117","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":450379832,"identity":"a536d0fb-b847-4433-a83b-662dc946ce6a","order_by":0,"name":"Funda Başyiğit","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYBAC9gYQaWAjx8DAQ6QWnmMgsiLNmFQtZw4nNhCvRb7H7MHPNub0DcfPHnzwgcFOTreBkBY2HnPD3ja23A1n8pINZzAkG5sdIKDFno3HTIK3jSd3w4EcM2kehgOJ2whpAdpiJvm3TSLd4PwbErRI85wxSDC4QbwtaWXSMhUJhjNvvDE2nGFAhF94mA9vk3xj8F+e73yO4YMPFXZyBLXAgQJYpQGxykFAvoEU1aNgFIyCUTCiAACgtjyGE3gy3gAAAABJRU5ErkJggg==","orcid":"","institution":"Ankara Etlik City Hospital","correspondingAuthor":true,"prefix":"","firstName":"Funda","middleName":"","lastName":"Başyiğit","suffix":""},{"id":450379833,"identity":"debc2469-c003-4733-9f0b-c95719a14f8e","order_by":1,"name":"Emine Cansu Yücel","email":"","orcid":"","institution":"Ankara Etlik City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Emine","middleName":"Cansu","lastName":"Yücel","suffix":""},{"id":450379834,"identity":"2c30f80d-dff3-4194-ace0-002484b09f22","order_by":2,"name":"Oğuz Uçar","email":"","orcid":"","institution":"Ankara Etlik City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Oğuz","middleName":"","lastName":"Uçar","suffix":""},{"id":450379835,"identity":"0cca36e3-52a3-4c1d-a2a2-d54415a113b2","order_by":3,"name":"Nazlı Turan","email":"","orcid":"","institution":"Ankara Etlik City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nazlı","middleName":"","lastName":"Turan","suffix":""},{"id":450379836,"identity":"7ac73287-4118-47b5-b176-a9b0760c68d2","order_by":4,"name":"Belma Yaman","email":"","orcid":"","institution":"Ankara Etlik City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Belma","middleName":"","lastName":"Yaman","suffix":""},{"id":450379837,"identity":"5cd583f2-f96e-42cb-8eba-4b4feba1b90e","order_by":5,"name":"Arzu Neslihan Akgün","email":"","orcid":"","institution":"Ankara Etlik City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Arzu","middleName":"Neslihan","lastName":"Akgün","suffix":""},{"id":450379838,"identity":"6ba567e0-83c1-4615-9a6b-dacebe38bf8f","order_by":6,"name":"Mustafa Mücahit Balcı","email":"","orcid":"","institution":"Ankara Etlik City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mustafa","middleName":"Mücahit","lastName":"Balcı","suffix":""},{"id":450379839,"identity":"1b1dfa68-f9df-43f8-9745-1a4e70293f32","order_by":7,"name":"Hatice Tolunay","email":"","orcid":"","institution":"Ankara Etlik City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hatice","middleName":"","lastName":"Tolunay","suffix":""}],"badges":[],"createdAt":"2025-04-26 16:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6536117/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6536117/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12959-025-00751-7","type":"published","date":"2025-07-01T15:58:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82160349,"identity":"57d1dcdb-2e0b-41d8-b068-5ae6b0da5158","added_by":"auto","created_at":"2025-05-07 08:32:01","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":67557,"visible":true,"origin":"","legend":"\u003cp\u003eROC Curves of sPESI, RDW-SD/Alb, sPESI+RDW-SD/Alb for predicting 6-month all-cause death.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6536117/v1/9fed2d9e940c685fd8dc2e29.jpeg"},{"id":82161802,"identity":"c27ef556-baf4-4f48-9d0e-ceebe47fd5fd","added_by":"auto","created_at":"2025-05-07 08:40:01","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58545,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier analysis of the impact of RDW-SD/Alb \u0026gt; 13.6 cut-off value on survival.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6536117/v1/a687a08c610511a4cbf15825.jpeg"},{"id":86180235,"identity":"37b2b3b7-e87e-4950-95a8-9778b62cd55d","added_by":"auto","created_at":"2025-07-07 16:21:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1055837,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6536117/v1/4e2dba9c-730c-450a-ac74-cd04632164c0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Red Cell Distribution Width–Standard Deviation to Albumin Ratio and Mortality in Acute Pulmonary Thromboembolism: A Single-Center Retrospective Cohort Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePulmonary embolism (PE) denotes obstruction of the pulmonary artery and can be induced by many origins, including tumors, fat, air, amniotic fluid, and septic emboli, though the extended majority are thromboembolic.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e After ischemic heart disease and stroke, PE is the third foremost cause of cardiovascular mortality worldwide.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRed blood cell distribution width (RDW) is a parameter routinely reported in the complete blood count (CBC) test, indicating the variability in the size of red blood cells in peripheral blood, and it is traditionally utilized clinically for the differential diagnosis of anemias. Recent evidence confirms that anisocytosis is common in human disorders such as cancer, liver failure, diabetes, cardiovascular disease, venous thromboembolism, community-acquired pneumonia, chronic obstructive pulmonary disease, kidney failure, and other acute or chronic conditions. Furthermore, the value of RDW is now believed to be a decisive and independent risk factor for death in the general population.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Serum albumin is a protein produced by the liver that serves as a negative acute phase reactant, meaning its levels decrease in response to inflammation.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e This protein plays several important roles, including acting as an anti-inflammatory agent, antioxidant, anticoagulant, and preventing platelet aggregation.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e RDW/Albumin (RAR) is a novel inflammatory biomarker that has been linked to mortality in various diseases, including chronic obstructive pulmonary disease, myocardial infarction, diabetic ketoacidosis, acute respiratory distress syndrome, and PE.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The simplified pulmonary embolism severity index (sPESI) has been developed from the more complex PESI score, which predicts the risk of death in patients with acute PE (APE) using only clinical indices.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Although nearly 20% of patients receiving treatment for PE die within 90 days, PE is not typically the direct cause of death; rather, it often occurs alongside other serious conditions such as cancer, sepsis, or illnesses that necessitate hospitalization.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Therefore, incorporating RAR into the sPESI score may enhance its prognostic value.\u003c/p\u003e \u003cp\u003eSo far, only two studies have investigated the prognostic value of RAR in acute pulmonary embolism (APE).\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Our goal is to determine whether RDW-Standard deviation/Albumin (RDW-SD/Alb) can serve as a valuable prognostic marker in APE and whether it can improve the prognostic power of the sPESI score.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study is a single-center, retrospective analysis implicating patients 18 years of age or older. A total of 235 consecutive patients who were hospitalized with a confirmed diagnosis of APE and were consulted to the cardiology department from the emergency department between February 2023 and March 2024 were screened. These patients were followed until October 2024.\u003c/p\u003e \u003cp\u003ePatients were excluded if they had end-stage liver disease, a glomerular filtration rate (GFR) of less than 15 mL/min, a left ventricular ejection fraction of less than 30%, severe valvular heart disease, or congenital heart disease. Ultimately, we included 184 survivor patients and 51 non-survivor patients [male 46.2%, median age 66,0 (23.0) years; 49.0% male, median age 74,0 (18.0) years].\u003c/p\u003e \u003cp\u003eBlood samples were collected upon admission, and CBCs were performed using the Sysmex XT 4000i machine for each patient. The ratio of RDW-SD to albumin was calculated by dividing the RDW-SD (fL) by the albumin level (g/dL).\u003c/p\u003e \u003cp\u003eWe gathered the clinical history, laboratory test results, transthoracic echocardiography (TTE) findings, and pulmonary computed tomographic angiography (CTA) results from the electronic medical reports in our hospital. All laboratory tests, TTE examinations, and CTA results for the patients were obtained within 24 hours of their admission to the emergency department.\u003c/p\u003e \u003cp\u003eThe sPESI score was calculated for each patient by the two different cardiologists. The score included variables such as age, history of cancer, chronic pulmonary disease, heart rate, systolic blood pressure (SBP), and oxygen saturation. 1 point is assigned for each of these situations; age is over 80 years, heart rate\u0026thinsp;\u0026ge;\u0026thinsp;110 beats/minute, SBP\u0026thinsp;\u0026lt;\u0026thinsp;100 mmHg, or arterial oxygen saturation\u0026thinsp;\u0026lt;\u0026thinsp;90%.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eWe examined all the data using SPSS version 22.0 software (SPSS Inc., Chicago, IL). Continuous data were delivered as either mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for parametric data or median\u0026thinsp;\u0026plusmn;\u0026thinsp;interquartile range for nonparametric data. Parametric continuous variables were assessed using the Independent Samples T-test, while nonparametric continuous variables were evaluated using the Mann-Whitney U test. We compared categorical data using Pearson's Chi-square test.\u003c/p\u003e \u003cp\u003eThe area under the receiver operating characteristic (ROC) curve was analyzed using the MedCalc program (MedCalc Software Ltd). The DeLong test compared the area under the ROC curves (AUROC). For patients with RDW-SD/Alb levels greater than 13.6, we assigned 1 point; otherwise, 0 points were counted for the sPESI score, resulting in a new score referred to as sPESI plus RDW-SD/Alb. We used ROC curves to determine the sensitivity and specificity of RDW-SD/Alb, sPESI, and the sPESI plus RDW-SD/Alb score in predicting 6-month all-cause death and compared the AUROC of both the sPESI and the sPESI plus RDW-SD/Alb score.\u003c/p\u003e \u003cp\u003eWe performed Kaplan-Meier analysis to evaluate the impact of higher RDW-SD/Alb levels (\u0026gt;\u0026thinsp;13.6) on patient survival time. We selected variables with a \u003cem\u003eP\u003c/em\u003e-value of less than 0.05 in the univariate Cox regression analysis for multivariate Cox regression analysis. Multivariate Cox regression analysis was utilized to specify the effect of independent prognostic factors on patient survival. Four different models were used: one unadjusted model and three adjusted models with increasing numbers of adjusted factors. The outcomes were evaluated at a 95% confidence interval, with significance considered at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eWe analyzed 235 consecutive patients diagnosed with APE, as revealed by pulmonary CTA, and separated them into the survivor group (n\u0026thinsp;=\u0026thinsp;184, 46.2% male, mean age\u0026thinsp;=\u0026thinsp;66.0\u0026thinsp;\u0026plusmn;\u0026thinsp;23.0 years) and non-survivor group \u003cem\u003e(\u003c/em\u003en\u0026thinsp;=\u0026thinsp;51, 49.0% male, mean age\u0026thinsp;=\u0026thinsp;74.0\u0026thinsp;\u0026plusmn;\u0026thinsp;18.0 years). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e outlines the demographic and clinical data, while Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides the laboratory parameters for survivors and non-survivors. Hypertension (60.8% \u003cem\u003evs\u003c/em\u003e. 45.1%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.047), diabetes (35.3% \u003cem\u003evs\u003c/em\u003e. 21.7%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.047), and chronic obstructive pulmonary disease (27.5% \u003cem\u003evs\u003c/em\u003e. 14.7%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.033) were more prevalent in non-survivor group than survivor group. The neutrophil (7.83\u0026thinsp;\u0026plusmn;\u0026thinsp;5.92 \u003cem\u003evs\u003c/em\u003e. 6.64\u0026thinsp;\u0026plusmn;\u0026thinsp;4.85, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.043), hs-troponin (48.7\u0026thinsp;\u0026plusmn;\u0026thinsp;41.2 \u003cem\u003evs\u003c/em\u003e. 31.2\u0026thinsp;\u0026plusmn;\u0026thinsp;44.3, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007), NT-Pro-Brain natriuretic peptide (NT-Pro-BNP) (2902\u0026thinsp;\u0026plusmn;\u0026thinsp;2448 \u003cem\u003evs\u003c/em\u003e. 1802\u0026thinsp;\u0026plusmn;\u0026thinsp;2609, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004), C-reactive protein (CRP) (68.5\u0026thinsp;\u0026plusmn;\u0026thinsp;100.5 \u003cem\u003evs\u003c/em\u003e. 45.9\u0026thinsp;\u0026plusmn;\u0026thinsp;63.5, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006) and RDW-SD/Alb (14.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8 \u003cem\u003evs\u003c/em\u003e. 12.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006) were higher in non-survivor group than survivor group, while lymphocyte (0.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10 \u003cem\u003evs\u003c/em\u003e. 1.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.23, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was lower.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Patient Characteristics of Participants, Survivors and Non-Survivors\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurvivor\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;184\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-Survivor\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;51\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.0\u0026thinsp;\u0026plusmn;\u0026thinsp;23.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.0\u0026thinsp;\u0026plusmn;\u0026thinsp;18.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender, male, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (46,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (49.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.721\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHT, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (45.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (60.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.047\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDM, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.047\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCOPD, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (27.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.033\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCVD, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDVT, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (37.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.486\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDyspnea\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145 (78.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (86.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.234\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHemoptysis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.970\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChest pain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (45.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSyncope\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.590\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBP, mmHg\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120.0\u0026thinsp;\u0026plusmn;\u0026thinsp;28.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120\u0026thinsp;\u0026plusmn;\u0026thinsp;32.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeart Rate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.0\u0026thinsp;\u0026plusmn;\u0026thinsp;27.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.0\u0026thinsp;\u0026plusmn;\u0026thinsp;26.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eArterial Saturation, %\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePulmoner Emboli Severity*, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntermediate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136 (73.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (86.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (13.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003esPESI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eCOPD, chronic obstructive pulmonary disease; CVD, cerebrovascular disease; DM, diabetes mellitus; DVT, deep vein thrombosis; HT, hypertension;SBP, systolic blood pressure; sPESI, simplified pulmonary embolism severity index;\u003c/p\u003e \u003cp\u003ePulmoner Emboli Severity* \u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory Parameters of Survivors and Non-Survivors\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurvivor\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;184\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-Survivor\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;51\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCreatinine, mg/dl\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.84\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.790\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSodyum, mmol/l\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e137\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLaktat, mmol/l\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.027\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAST, u/l\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0\u0026thinsp;\u0026plusmn;\u0026thinsp;29.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRBC, 10^\u003c/b\u003e\u003csup\u003e\u003cb\u003e6\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/ul\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.340\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHb, g/dl\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHematocrit, %\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMCV, fL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.977\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMCH, pg\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.275\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlatelet, 10^3/uL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e258.0\u0026thinsp;\u0026plusmn;\u0026thinsp;70.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e239.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.046\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWBC, 10^3/uL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.38\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.97\u0026thinsp;\u0026plusmn;\u0026thinsp;6.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.380\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeutrophil, 10^\u003c/b\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/uL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.64\u0026thinsp;\u0026plusmn;\u0026thinsp;4.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.83\u0026thinsp;\u0026plusmn;\u0026thinsp;5.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLymphocyte, 10^\u003c/b\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/uL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ehs-Troponin T, ng/L\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.2\u0026thinsp;\u0026plusmn;\u0026thinsp;44.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.7\u0026thinsp;\u0026plusmn;\u0026thinsp;41.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNT-ProBNP, pg/mL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1802\u0026thinsp;\u0026plusmn;\u0026thinsp;2609\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2902\u0026thinsp;\u0026plusmn;\u0026thinsp;2448\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD-Dimer, \u0026micro;g/mL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.43\u0026thinsp;\u0026plusmn;\u0026thinsp;2.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.43\u0026thinsp;\u0026plusmn;\u0026thinsp;3.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.112\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCRP, mg/L\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.9\u0026thinsp;\u0026plusmn;\u0026thinsp;63.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.5\u0026thinsp;\u0026plusmn;\u0026thinsp;100.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRDW-SD, fL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlbumin, g/dL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRDW-SD/Alb, fL.dL/g\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAST, aspartate aminotransferase; BNP, brain natriuretic peptide; CRP, C reactive protein; Hb, hemoglobin; MCH, mean corpuscular hemoglobin; MCV, mean corpuscular volume; RAR, red cell distribution-standard deviation/albumin width ratio; RBC, red blood cell; RDW-SD, red cell distribution-standard deviation; WBC, white blood cell\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe cut-off value of RDW-SD/Alb for 6-month all-cause death was 13.6. RDW-SD/Alb higher than 13.6 predicted the 6-month all-cause death with a sensitivity of 70.6% and specificity of 67.0% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eAUROC values for the variables analyzed by ROC curve analysis in terms of predicting 6-month all-cause death in APE were as follows: RDW-SD/Alb: AUC: 0.727 (95% CI: 0.666\u0026ndash;0.784, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), sPESI: AUC: 0.708 (95% CI: 0.645\u0026ndash;0.765, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), sPESI plus RDW-SD/Alb score: AUC: 0.740 (95% CI: 0.679\u0026ndash;0.795, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). After the pairwise comparison by the Delong test, AUROC of sPESI plus RDW-SD/Alb score was statistically larger than the AUROC of sPESI (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWe generated Kaplan\u0026ndash;Meier survival curves for patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The mortality rate in the RDW-SD/Alb\u0026thinsp;\u0026gt;\u0026thinsp;13.6 group was significantly greater compared to the RDW-SD/Alb\u0026thinsp;\u0026le;\u0026thinsp;13.6 group (Log-rank, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In the fully adjusted model, RDW-SD/Alb\u0026thinsp;\u0026gt;\u0026thinsp;13.6 group was definitively associated with all-cause mortality within a six-month period following admission. We have installed three adjustment models (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In Model 1, adjusted for age and diabetes, and Model 2, adjusted for age, diabetes, heart rate, and arterial oxygen saturation (ASAT), we observed a statistically remarkable increase in the risk of all-cause mortality within 6 months after hospital admission for patients with RDW-SD/Alb\u0026thinsp;\u0026gt;\u0026thinsp;13.6. Compared to the lower RDW-SD/Alb group (\u0026le;\u0026thinsp;13.6), patients in the higher RDW-SD/Alb group (\u0026gt;\u0026thinsp;13.6) showed elevated 6-month all-cause mortality (OR 2.755, 95% CI 1.420, 5.345, p\u0026thinsp;=\u0026thinsp;0.003) in the Model 3, adjusted for age, diabetes, heart rate, ASAT, aspartate aminotransferase (AST), troponin, CRP, and the sPESI score. Other independent prognostic factors on survival in the Model 3 were age and AST (HR 1.030, 95% CI 1.005, 1.056, p\u0026thinsp;=\u0026thinsp;0.018; HR 1.020, 95% CI 1.008, 1.032, p\u0026thinsp;=\u0026thinsp;0.003, respectively). Furthermore, there was a statistically significant difference between Model 1 and Model 2, but no significant difference between Model 2 and Model 3 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; p\u0026thinsp;=\u0026thinsp;0.076, respectively).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHazard ratios (HRs) for 6-month mortality based on RDW-SD/Alb in acute pulmonary embolism\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCrude Model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eModel I\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eModel II\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eModel III\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHR(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHR(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHR(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e6-month all\u003c/p\u003e \u003cp\u003ecause mortality\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRAR\u0026thinsp;\u0026le;\u0026thinsp;13.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRAR\u0026thinsp;\u0026gt;\u0026thinsp;13.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.081\u003c/p\u003e \u003cp\u003e(2.152\u0026ndash;7.739)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.369\u003c/p\u003e \u003cp\u003e(1.765\u0026ndash;6.430)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.229\u003c/p\u003e \u003cp\u003e(1.696\u0026ndash;6.149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.755\u003c/p\u003e \u003cp\u003e(1.420\u0026ndash;5.345)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003eCrude model: we did not adjust other covariants.\u003c/p\u003e \u003cp\u003eModel I: we adjusted age and diabetes.\u003c/p\u003e \u003cp\u003eModel II: we adjusted age, diabetes, heart rate and ASAT.\u003c/p\u003e \u003cp\u003eModel III: we adjusted age, diabetes, heart rate and ASAT, AST, troponin, CRP and sPESI score.\u003c/p\u003e \u003cp\u003eASAT\u0026thinsp;=\u0026thinsp;arterial saturation, AST\u0026thinsp;=\u0026thinsp;aspartate aminotransferase, CI\u0026thinsp;=\u0026thinsp;confidence interval, CRP\u0026thinsp;=\u0026thinsp;C-reactive protein, Cre\u0026thinsp;=\u0026thinsp;creatinine, HR\u0026thinsp;=\u0026thinsp;hazard ratio, RDW-SD/Alb\u0026thinsp;=\u0026thinsp;red blood cell distribution width-standard deviation to albumin ratio, Ref\u0026thinsp;=\u0026thinsp;reference, sPESI: simplified pulmonary embolism severity index.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe results of our study identified three main findings: First, the RDW-SD/Alb ratio was higher in the non-survivor group than in the survivor group among patients with APE. Second, the cut-off value RDW-SD/Alb for the predicting 6-month all-cause mortality was determined to be 13.6. Third, an RDW-SD/Alb greater than 13.6 was associated with an expanded risk of 6-month all-cause mortality. Additionally, the predictive value of the sPESI score for 6-month all-cause death improved when the RDW-SD/Alb\u0026thinsp;\u0026gt;\u0026thinsp;13.6 parameter was included. Finally, RDW-SD/Alb levels greater than 13.6, along with age and AST, were independent prognostic factors for survival in patients with APE.\u003c/p\u003e \u003cp\u003eThe relationship between RDW and venous thromboembolism is complex and is still under investigation. It is well established that various nutritional deficiencies can occur in patients who experience chronic immobilization and declining renal function, both of which are common in individuals with deep vein thrombosis (DVT) and PE. Additionally, hypoxia caused by the obstruction of pulmonary arteries may lead to the hyperactivation of adrenergic and neurohormonal pathways, triggering the release of pro-inflammatory cytokines. Salvano et al. observed that RDW may be elevated due to the intricate interactions among these underlying conditions in patients with APE.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Albumin is a medium-sized protein synthesized by the liver and plays a key role in supporting colloid osmotic pressure in the body. Like RDW, albumin is important for the inflammatory response and oxidative stress.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Numerous studies have indicated that low levels of albumin are related to poor prognosis in patients with APE.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e In this study, the combination of RDW-SD and albumin, referred to as RDW-SD/Alb, was linked to all-cause mortality in patients with APE, even after adjusting for various other factors.\u003c/p\u003e \u003cp\u003eAPE is classified into three categories based on imaging findings and patient characteristics: high-risk, intermediate-risk, and low-risk. High-risk PE is defined by sustained hypotension, indicated by a SBP of less than 90 mm Hg for at least 15 minutes or a vasopressor requirement with no other plausible explanation for the shock. Intermediate-risk PE includes patients who exhibit signs of right ventricular (RV) dysfunction through imaging or biomarker evidence (such as myocardial necrosis or chamber dilation) but do not show sustained hypotension. A subcategory of intermediate-risk, intermediate-high-risk PE involves patients with both imaging and biomarker evidence of RV dysfunction. Low-risk PE does not fulfill the criteria for high-risk or intermediate-risk PE.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Severe PE patients with SBP greater than 90 mm Hg are categorized according to their risk of hemodynamic collapse and death. Individual risk factor-based clinical prediction scores can be used to identify patient subgroups at high risk for hemodynamic instability. Despite the large number of published clinical prediction scores, only a few numbers have been prospectively validated and shown to be trustworthy.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e These include the Bova score, the PESI, and sPESI scores. The Bova score combines high troponin levels and RV dysfunction with hemodynamic instability criteria, whereas the PESI and sPESI scores combine markers of cardiopulmonary impairment with age and comorbidities.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The European Society of Cardiology guidelines recommend using PESI, an algorithm that calculates various clinical and hemodynamic indicators, to predict 30-day mortality. Due to the complexity of the original PESI, which consists of 11 differently weighted variables, a simplified version called sPESI has been developed and validated. A sPESI score of 0 identifies a low-risk group, with an approximately 1.0% mortality risk within 30 days. In contrast, a sPESI score of 1 or higher identifies a high-risk group, with a 30-day mortality risk increasing to 10.9%.\u003csup\u003e14\u003c/sup\u003e Additionally, markers of RV dysfunction, including ECG, TTE, BNP, and troponin levels, are commonly used for prognostic evaluation in patients with APE. According to retrospective investigations, scoring systems that use biomarkers like the BOVA score are better than the sPESI score at predicting the likelihood of unfavorable events in the early stages.\u003csup\u003e\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Although the sPESI score is a powerful tool for excluding adverse events in patients with a score of 0, its predictive power for mortality in patients with a score of \u0026ge;\u0026thinsp;1 is still in doubt. Trimaille et al. examined whether the sPESI score's capacity to predict death was enhanced by including renal dysfunction.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e The findings demonstrated that a group with extremely high mortality was found when renal failure was included as a biomarker to the sPESI score. This implies that more biomarkers are required to help the sPESI score more accurately predict the likelihood of unfavorable outcomes. In the present study, although the sPESI score was higher in the non-survivor group, both groups had high-risk sPESI scores. In light of these findings, RDW-SD/Alb might be thought of as a predictor of all-cause mortality among patients with high-risk features. Furthermore, we observed that the predictive value of the sPESI score for six-month all-cause death improved when RDW-SD/Alb\u0026thinsp;\u0026gt;\u0026thinsp;13.6 was included as a parameter. Therefore, in addition to the sPESI score, RDW-SD/Alb can be utilized as a biomarker to predict early mortality in individuals with APE more precisely.\u003c/p\u003e \u003cp\u003eRecently, Ding et al. examined the relationship between RAR levels and the risk of all-cause mortality in patients with APE admitted to the intensive care unit (ICU). The researchers categorized the patients into three groups according to their RAR levels: Low RAR (2.68\u0026ndash;4.71), Middle RAR (4.71\u0026ndash;6.09), and High RAR (6.09\u0026ndash;15.45). The study found a significant association between the Middle and High RAR groups and an increased risk of all-cause mortality in patients with PE.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Furthermore, our study indicated that higher RDW-SD/Alb (\u0026gt;\u0026thinsp;13.6) was associated with 6-month all-cause mortality, not only in ICU patients diagnosed with APE but also in all hospitalized patients with this condition.\u003c/p\u003e \u003cp\u003eEraslan et al. evaluated the impact of RAR on mortality in patients with PE.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Their analysis identified a cut-off value of 5.294 using ROC analysis. Patients with an RAR of 5.294 or higher had a significantly shorter mean survival time compared to those with an RAR below this threshold. In our study, we established that the RDW-SD/Alb cut-off value predicting all-cause death at six months was 13.6. It is important to note that Eraslan et al. calculated the RAR using the RDW-CV (%) unit, whereas we utilized the RDW-SD (fL) unit. We believe the differing cut-off values between the two studies may be attributed to this distinction. Recent studies indicated that RDW-SD may offer additional diagnostic value, as it is a direct measurement that is not influenced by mean corpuscular volume and more accurately reflects variations in red cell size.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e There is insufficient data in the literature about whether RDW-SD or RDW-CV should be used for calculating RAR.\u003c/p\u003e \u003cp\u003eOur study has several limitations. First, it was a single-center, retrospective, observational study, which inherently has limitations due to its design. Second, data on the study population were obtained from our hospital's electronic medical records, which may introduce a selective bias.\u003c/p\u003e \u003cp\u003eThird, RDW-SD/Alb is a recently identified inflammatory marker, and a prospective study is necessary to more accurately determine its predictive cut-off value in patients with APE.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOur study has identified RDW-SD/Alb as a new independent inflammatory marker that can predict 6-month all-cause mortality in patients with APE. This marker is low-cost and easy to use, providing valuable early information. As a novel parameter, RDW-SD/Alb may improve the management of APE patients by aiding in the prediction of 6-month mortality risk. It may be advisable to closely monitor APE patients with an RDW/Alb\u0026thinsp;\u0026gt;\u0026thinsp;13.6.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAPE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Acute pulmonary emolism\u003c/p\u003e\n\u003cp\u003eASAT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Arterial oxygen saturation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAST \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Aspartate aminotransferase\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCBC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Complete blood count\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCRP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C-reactive protein\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCTA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Computed tomographic angiography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDVT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Deep vein thrombosis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGFR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Glomerular filtration rate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNT-Pro-BNP \u0026nbsp; \u0026nbsp; NT-Pro-Brain natriuretic peptide\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Pulmonary embolism\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRAR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Red blood cell distribution width (RDW) / Albumin\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRDW \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Red blood cell distribution width\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRDW-SD/Alb \u0026nbsp; RDW-Standard Deviation/Albumin\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eROC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Receiver operating characteristic\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003esPESI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Simplified pulmonary embolism severity index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTTE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Transthoracic echocardiography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study protocol has been approved by the ethics committee at our center and was implemented per the principles of the Declaration of Helsinki. We did not obtain informed consent because the study was designed retrospectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available on request from the corresponding author and with permission from our hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFB: Conceptualization, Formal Analysis, Methodology, Project administration, Validation, Visualization, Writing \u0026ndash; review \u0026amp; editing. ECY: Investigation, Validation, Visualization. OU: Formal Analysis, Investigation, Project administration. NT: Validation, Visualization, Writing \u0026ndash; original draft. BY: Writing \u0026ndash; review \u0026amp; editing. ANA: Methodology, Project administration. MMA: Methodology, Project administration. HT: Visualization, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe gratefully acknowledge the comforting presence of our beloved cat, Hashmet Tuna, whose companionship brought us joy and serenity while preparing this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBirrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. 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Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism. Heart. 1997;77(4):346\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlok FA, Mos IC, Huisman MV. Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis. Am J Respir Crit Care Med. 2008;178(4):425\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShopp JD, Stewart LK, Emmett TW, et al. Findings From 12-lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta-analysis. Acad Emerg Med. 2015;22(10):1127\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrimaille A, Marchandot B, Girardey M et al. Assessment of Renal Dysfunction Improves the Simplified Pulmonary Embolism Severity Index (sPESI) for Risk Stratification in Patients with \u003cem\u003eAcute Pulmonary Embolism\u003c/em\u003e. J Clin Med. 2019;8(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoffmann J, Urrechaga E. Role of RDW in mathematical formulas aiding the differential diagnosis of microcytic anemia. Scand J Clin Lab Invest. 2020;80(6):464\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaporal FA, Samuel Ricardo Comar. Evaluation of RDW-CV, RDW-SD, and MATH-1SD for the detection of erythrocyte anisocytosis observed by optical microscopy. J Bras Patol Med Lab. 2013;49(5):324\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"thrombosis-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"thrj","sideBox":"Learn more about [Thrombosis Journal](http://thrombosisjournal.biomedcentral.com/)","snPcode":"12959","submissionUrl":"https://submission.nature.com/new-submission/12959/3","title":"Thrombosis Journal","twitterHandle":"@Thrombosis_J","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pulmonary embolism, Red cell distribution width, Albumin, Venous Thrombosis, sPESI Score","lastPublishedDoi":"10.21203/rs.3.rs-6536117/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6536117/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRecent studies have shown a relation between red blood cell distribution width (RDW) / albumin (RAR) levels and worse outcomes in cases of pulmonary embolism (PE). Simplified pulmonary embolism severity index (sPESI) has been developed from more complex PESI score, predicting the risk of death in patients with acute PE (APE). This study aims to investigate whether RDW-Standard Deviation/Albumin (RDW-SD/Alb) can serve as a useful prognostic marker for APE and enhance the predictive capability of the sPESI.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis research is a single-center, retrospective analysis involving patients over 18 years. We enrolled 235 consecutive hospitalized patients with confirmed APE diagnoses. To evaluate the sensitivity and specificity of RDW-SD/Alb, sPESI, and the combined sPESI plus RDW-SD/Alb in predicting 6-month all-cause death, we used Receiver Operating Characteristic (ROC) curves. Additionally, we conducted Kaplan-Meier analysis to assess the impact of elevated RDW-SD/Alb levels (\u0026gt;\u0026thinsp;13.6) on patient survival time. We utilized multivariate Cox regression analysis to identify independent prognostic factors affecting patients survival.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mortality rate for RDW-SD/Alb\u0026thinsp;\u0026gt;\u0026thinsp;13.6 group was significantly higher than that for the RDW-SD/Alb\u0026thinsp;\u0026le;\u0026thinsp;13.6 group. Area under ROC (AUROC) of sPESI plus RDW-SD/Alb was statistically larger than AUROC of sPESI (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025). In the fully adjusted model, increased RDW-SD/Alb levels were consistently linked to all-cause mortality within six months of admission.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe predictive value of the sPESI for 6-month all-cause death improved when the RDW-SD/Alb\u0026thinsp;\u0026gt;\u0026thinsp;13.6 parameter was included. RDW-SD/Alb\u0026thinsp;\u0026gt;\u0026thinsp;13.6, a novel inflammatory marker, was an independent prognostic factor for survival in patients with APE.\u003c/p\u003e","manuscriptTitle":"Red Cell Distribution Width–Standard Deviation to Albumin Ratio and Mortality in Acute Pulmonary Thromboembolism: A Single-Center Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 08:31:56","doi":"10.21203/rs.3.rs-6536117/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-21T00:48:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-12T19:36:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104167238373151205198260139695025355713","date":"2025-04-30T08:27:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-30T03:08:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-28T15:01:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-28T14:56:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"Thrombosis Journal","date":"2025-04-26T16:20:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"thrombosis-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"thrj","sideBox":"Learn more about [Thrombosis Journal](http://thrombosisjournal.biomedcentral.com/)","snPcode":"12959","submissionUrl":"https://submission.nature.com/new-submission/12959/3","title":"Thrombosis Journal","twitterHandle":"@Thrombosis_J","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"10cd5369-16ef-42b4-9478-1c0a54972c84","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:16:02+00:00","versionOfRecord":{"articleIdentity":"rs-6536117","link":"https://doi.org/10.1186/s12959-025-00751-7","journal":{"identity":"thrombosis-journal","isVorOnly":false,"title":"Thrombosis Journal"},"publishedOn":"2025-07-01 15:58:10","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2025-05-07 08:31:56","video":"","vorDoi":"10.1186/s12959-025-00751-7","vorDoiUrl":"https://doi.org/10.1186/s12959-025-00751-7","workflowStages":[]},"version":"v1","identity":"rs-6536117","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6536117","identity":"rs-6536117","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}