Contemporary Management and Outcomes of Patients With High-Risk Pulmonary Embolism
Key result
High-risk PE is linked to ~6-fold higher in-hospital mortality compared to intermediate-risk PE.
- P<0.001
- n=5,790
Why the study?
Contemporary care patterns and outcomes in high-risk pulmonary embolism patients are unknown.
Does high-risk pulmonary embolism increase in-hospital mortality compared to intermediate-risk pulmonary embolism?
Key Points
- To characterize contemporary clinical management and identify factors associated with poor in-hospital outcomes in patients presenting with high-risk pulmonary embolism.
- Retrospective analysis of 5,790 patients across 35 sites in the PERT (Pulmonary Embolism Response Team) Consortium Registry, categorizing patients into intermediate-risk PE (n = 2,976) and high-risk PE (n = 1,442).
- Subgroup evaluation identified catastrophic PE with hemodynamic collapse (n = 197) within the high-risk cohort.
- Covariates were analyzed using chi-square testing, Student's t-test, and multivariable logistic regression models for in-hospital mortality and major bleeding.
- In-hospital mortality was 20.6% in high-risk PE versus 3.7% in intermediate-risk PE (P < 0.001), and major bleeding occurred in 10.5% versus 3.5% (P < 0.001).
- Catastrophic PE patients experienced higher in-hospital mortality (42.1% vs 17.2%; P < 0.001) and greater use of systemic thrombolysis (25% vs 11.3%; P < 0.001) and extracorporeal membrane oxygenation (13.3% vs 4.8%; P < 0.001) than noncatastrophic high-risk PE patients.
- Multivariable logistic regression demonstrated that vasopressor use (OR: 4.56; 95% CI: 3.27–6.38; P < 0.01), extracorporeal membrane oxygenation (OR: 2.86; 95% CI: 1.12–7.30; P = 0.03), clot-in-transit (OR: 2.26; 95% CI: 1.13–4.52; P = 0.02), and malignancy (OR: 1.70; 95% CI: 1.13–2.56; P = 0.01) were significantly associated with in-hospital mortality.
Study Design
Type
Cohort (n=5,790)
Multicenter
Yes
Structured PICO
Does high-risk pulmonary embolism increase in-hospital mortality compared to intermediate-risk pulmonary embolism?
P
Population
5,790 patients with pulmonary embolism from the U.S. PERT Consortium Registry, comparing management and outcomes between intermediate-risk and high-risk presentations.
E
Exposure
High-risk pulmonary embolism (including catastrophic PE with hemodynamic collapse)
C
Comparator
Intermediate-risk pulmonary embolism
O
Outcome
In-hospital mortalityhard clinical
Main Result
Absolute Event Rate: 20.6% vs 3.7%
p-value: p=<0.001
High-risk pulmonary embolism carries a 20% in-hospital mortality rate, with catastrophic presentations exceeding 40%, highlighting the need for improved therapeutic strategies.
Limitations
- Selection, survival, and immortal time biases favoring relatively more stable patients
- Lack of power, particularly in the catastrophic PE cohort
- Does not capture patients who never had a PERT activation/consultation
- Designation for catastrophic PE was based on local PERT centers' discretion and could not be individually adjudicated
- Does not account for site-specific characteristics, preferences, or clustering in management
- Selection, survival, and immortal time biases
- Lack of power in catastrophic PE cohort
- Only includes PERT activations/consultations
- Catastrophic PE designation not individually adjudicated
- Does not account for site-specific characteristics
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
SVStavros V. KonstantinidesThrombosis and Hemostasis Center, University Medical Center Mainz
“High-risk PE is classically defined by 'hemodynamic instability' based on persistently low arterial blood pressure or collapse, necessitating cardiopulmonary resuscitation. It is associated with a very unfavorable early prognosis, with in-hospital mortality rates ranging from 20% to 50%, and rising to almost 85% if cardiac arrest occurs. Of all patients with acute PE, these are the patients who most urgently need effective life-saving treatment, but this is also the PE risk class with the largest knowledge gaps regarding optimal management to date.”
“We expect randomized controlled trials evaluating a total of nearly 3,000 patients to report their results over the next 2 years, and the results of these trials are sure to influence the guidelines, with processes in place for more rapid incorporation of these results into guideline updates than in the past.”
“There have been significant advances in the understanding of pulmonary embolism and treatments to effectively manage this condition. This guideline is a road map to help clinicians navigate these advances for the safest and most effective approaches to care for people with this condition.”
Implication
High-risk PE mortality exceeds 20%; extends risk stratification in registry data but leaves optimal interventions open for RCTs.
Abstract
BACKGROUND Contemporary care patterns/outcomes in high-risk pulmonary embolism (PE) patients are unknown. OBJECTIVES This study sought to characterize the management of high-risk PE patients and identify factors associated with poor outcomes. METHODS A retrospective analysis of the PERT (Pulmonary Embolism Response Team) Consortium Registry was performed. Patients presenting with intermediate-risk PE, high-risk PE, and catastrophic PE (those with hemodynamic collapse) were identified. Patient characteristics were compared with chi-square testing for categorical covariates and Student’s t-test for continuous covariates. Multivariable logistic regression was used to assess associations between clinical characteristics and outcomes in the high-risk population. RESULTS Of 5,790 registry patients, 2,976 presented with intermediate-risk PE and 1,442 with high-risk PE. High-risk PE patients were more frequently treated with advanced therapies than intermediate-risk PE patients (41.9% vs 30.2%; P < 0.001). In-hospital mortality (20.6% vs 3.7%; P < 0.001) and major bleeding (10.5% vs. 3.5%; P < 0.001) were more common in high-risk PE. Multivariable regression analysis demonstrated vasopressor use (OR: 4.56; 95% CI: 3.27–6.38; P < 0.01), extracorporeal membrane oxygenation use (OR: 2.86; 95% CI: 1.12–7.30; P = 0.03), identified clot-in-transit (OR: 2.26; 95% CI: 1.13–4.52; P = 0.02), and malignancy (OR: = 1.70; 95% CI: 1.13–2.56; P = 0.01) as factors associated with in-hospital mortality. Catastrophic PE patients (n = 197 [13.7% of high-risk PE patients]) had higher in-hospital mortality (42.1% vs 17.2%; P < 0.001) than those presenting with noncatastrophic high-risk PE. Extracorporeal membrane oxygenation (13.3% vs. 4.8% P < 0.001) and systemic thrombolysis (25% vs 11.3%; P < 0.001) were used more commonly in catastrophic PE. CONCLUSIONS In the largest analysis of high-risk PE patients to date, mortality rates were high with the worst outcomes among patients with hemodynamic collapse.
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Cite This Study
Kobayashi et al. (2024) conducted a cohort in Pulmonary Embolism (n=5,790). High-risk pulmonary embolism vs. Intermediate-risk pulmonary embolism was evaluated on In-hospital mortality (p=<0.001). High-risk pulmonary embolism was associated with 20.6% in-hospital mortality compared to 3.7% for intermediate-risk, with vasopressor use, ECMO, clot-in-transit, and malignancy identified as significant mortality predictors.