Clinical presentation and prognosis of acute symptomatic pulmonary embolism in patients with concomitant upper-extremity versus lower-extremity deep vein thrombosis

BACKGROUND: The impact of deep vein thrombosis (DVT) location on acute pulmonary embolism (PE) prognosis remains uncertain. METHODS: Using the Registro Informatizado de Enfermedad TromboEmbólica registry, we assessed 30-day and 90-day outcomes in patients with acute symptomatic PE and concomitant upper-extremity (UEDVT) versus lower-extremity DVT (LEDVT). Cox regression was employed for analysis, and standardised differences (SRD) were used for reporting clinical characteristics to minimise type I error overinflation. The primary outcome was 30-day all-cause mortality, with secondary outcomes including 90-day mortality, fatal PE, venous thromboembolism (VTE) recurrences, and major bleeding. RESULTS: Among 21 617 patients with PE (March 2001-April 2023), 508 had UEDVT, and 21 109 had LEDVT. Patients with UEDVT were younger (SRD: 0.231), more often had cancer (SRD: 0.395) or non-central PEs (SRD: 0.445), but less frequently had raised troponin levels (SRD: 0.376) or right ventricle dysfunction (SRD: 0.249). Thirty-day mortality was higher in UEDVT compared with LEDVT (7.3% vs 3.5%; p<0.001), with similar trends at 90 days (14% vs 6.0%) and in subgroup analysis in patients without cancer. Increased rates of PE-related mortality, VTE recurrences and major bleeding were noted in patients with UEDVT at both 30 and 90 days. UEDVT was associated with a higher risk for 30-day (adjusted HR (aHR): 1.49; 95% CI 1.04 to 2.13) and 90-day (aHR: 1.52; 95% CI 1.15 to 2.00) all-cause mortality on multilevel multivariable analysis. CONCLUSIONS: Patients with concomitant UEDVT experienced worse short-term outcomes, including higher mortality, despite fewer clinical signs of PE severity compared with LEDVT. These findings suggest that unrecognised patient characteristics might influence prognosis, warranting further research.