When risk scores and conventional echo fail: RV strain in cancer patients with pumonary embolism

Background Cancer patients with pulmonary embolism (PE) have substantial short- and long-term mortality. Echocardiography is central to PE risk stratification, while strain imaging, by detecting subtle myocardial abnormalities, has several advantages over conventional echo parameters. Objective We aimed to evaluate the prognostic impact of RV functional assessment, with a focus on myocardial deformation imaging, in oncologic patients with acute PE hospitalized in a tertiary care center. Methods We retrospectively included consecutive cancer patients with PE hospitalized in our department between 2016 and 2025, who underwent echocardiographic assessment, including RV global longitudinal strain (RV-GLS) and RV free wall longitudinal strain (RVFW-LS). PE was classified as high-risk or non-high risk according to ESC criteria. The primary endpoint was in-hospital death. A predefined subgroup analysis was performed in patients with preserved TAPSE (≥ 17 mm). Results 217 patients were included in the study; 13 (6%) died during hospitalization. Patients who died had lower blood pressure (BP) on admission (p=0.006), higher pulmonary artery systolic pressure (PASP, p=0.01), and significantly more impaired RV function (p=0.008 for TAPSE, p<0.001 for S wave, RV-GLS, RVFW-LS). 25 patients had high-risk, while 192 patients had non-high risk PE. Among non-high risk patients, there were 7 deaths (4%). In univariable analysis, TAPSE, S wave, RV-GLS, RVFW-LS predicted in-hospital mortality for non-high risk patients. In ROC analysis, the strongest predictors of death were RVFW-LS and RV-GLS (AUC=0.93, p=0.001 for both). Both RV strain components remained independet event predictors after adjustment for age, systolic BP and PASP: OR=1.61 [95% CI, 1.13-2.29], p=0.008 for RV-GLS, OR=1.35 [95% CI, 1.08-1.67], p=0.007 for RVFW-LS. Moreover, in the subgroup of non-high risk patients with preserved TAPSE (n=160), RV-GLS and RVFW-LS remained death predictors (OR=1.30 [95%CI, 1.00-1.69], p=0.05 and OR=1.26 [95%CI, 1.03-1.54], p=0.02, respectively). Conclusions In cancer patients with non-high risk PE, RV strain identifies a vulnerable subgroup with increased in-hospital mortality, even when TAPSE is preserved. Strain analysis may improve risk stratification for this population and thus guide intensified monitoring and individualized treatment strategies.