October 19, 2018Open Access
Syncope in haemodynamically stable and unstable patients with acute pulmonary embolism – Results of the German nationwide inpatient sample
Key Result
Syncope in haemodynamically stable patients with acute pulmonary embolism was associated with a reduced risk of in-hospital death compared to those without syncope (6.4% vs. 7.6%, OR 0.68).
Study Design
Type
Observational (n=345,889)
Multicenter
Yes
Structured PICO
Does the presence of syncope or the use of systemic thrombolysis impact in-hospital mortality in patients with acute pulmonary embolism?
P
Population
345,889 inpatients (aged ≥ 18 years) with acute pulmonary embolism (293,640 haemodynamically stable and 52,249 unstable) from the German nationwide inpatient sample (2011-2014)
I
Intervention
Presence of syncope; systemic thrombolysis (in subgroup of haemodynamically stable PE with syncope)
C
Comparator
Absence of syncope; no systemic thrombolysis
O
Outcome
In-hospital mortalityhard clinical
Syncope in acute pulmonary embolism is associated with lower in-hospital mortality, and systemic thrombolysis may improve survival in haemodynamically stable PE patients presenting with syncope.
Main Result
Effect estimate: OR 0.68 (95% CI 0.61-0.75)
Absolute Event Rate: 6.4% vs 7.6%
p-value: p=<0.001
Limitations
- Based on ICD and OPS discharge codes which might lead to incomplete data due to under-reporting/under-coding
- Exact time point of haemodynamic instability could not be identified
- Important clinical data such as CT severity, troponin, echocardiographic parameters, or medications were not available
Abstract
Syncope in pulmonary embolism (PE) could be the first sign of haemodynamic compromise. We aimed to investigate pathomechanisms of syncope and its impact on mortality. For this study, patients (aged ≥ 18years) were selected by screening the German nationwide inpatient sample for PE and stratified included patients by syncope (2011-2014). We analysed predictors of syncope in haemodynamically stable PE. Impact of syncope on in-hospital mortality in haemodynamically stable and unstable PE and benefit of systemic thrombolysis in haemodynamically stable PE with syncope (PE + Syncope) were analyzed. The German nationwide inpatient sample comprised 293,640 (84.9%) haemodynamically stable and 52,249 (15.1%) unstable PE patients; among them 2.3% had syncope. Right ventricular dysfunction (RVD) was a key predictor for syncope. In-hospital mortality-rate was lower in haemodynamically stable (6.4% vs. 7.6%, P < 0.001) and unstable PE + Syncope than in PE-Syncope (48.4% vs. 55.5%, P < 0.001) with reduced risk for in-hospital death in stable (OR 0.68 (95%CI 0.61-0.75), P < 0.001) and unstable (OR 0.69 (95% CI 0.62-0.78), P < 0.001) inpatients independent of age and sex. Haemodynamically stable PE + Syncope patients were more often treated with systemic thrombolysis (3.1% vs. 2.1%, P < 0.001). Systemic thrombolysis was associated with reduced in-hospital mortality in haemodynamically stable PE + Syncope (1.9% vs. 6.6%, P = 0.004) independently of age, RVD and tachycardia (OR 0.30 (95%CI 0.11-0.82), P = 0.019). In conclusion, in-hospital mortality was 6.4% in haemodynamically stable PE + Syncope. Haemodynamically stable PE + Syncope patients were more often treated with systemic thrombolysis and showed a trend to improved survial.