Intermediate-High Risk Pulmonary Embolism.

Victor Tapson,Francisco León,Deisy Barrios,Rosa Mirambeaux,Behnood Bikdeli,Edwin Mercedes,Lisa Moores,David Jiménez,Raquel Morillo,Roger D Yusen

doi:10.1055/s-0039-3401003

Abstract

Limited information exists about the prevalence, management, and outcomes of intermediate-high risk patients with acute pulmonary embolism (PE). In a prospective cohort study, we evaluated consecutive patients with intermediate-high risk PE at a large, tertiary, academic medical center between January 1, 2015 and March 31, 2019. Adjudicated outcomes included PE-related mortality and a complicated course through 30 days after initiation of PE treatment. Repeat systolic blood pressure (SBP), heart rate (HR), brain natriuretic peptide (BNP), and cardiac troponin I (cTnI) measurements, and echocardiography were performed within 48 hours after diagnosis. Among 1,015 normotensive patients with acute PE, 97 (9.6%) had intermediate-high risk PE. A 30-day complicated course and 30-day PE-related mortality occurred in 23 (24%) and 7 patients (7.2%) with intermediate-high risk PE. Seventeen (18%) intermediate-high risk patients received reperfusion therapy. Within 48 hours after initiation of anticoagulation, normalization of SBP, HR, cTnI, BNP, and echocardiography occurred in 82, 86, 78, 72, and 33% of survivors with intermediate-high risk PE who did not receive immediate thrombolysis. A complicated course between day 2 and day 30 after PE diagnosis for the patients who normalized SBP, HR, cTnI, BNP, and echocardiography measured at 48 hours occurred in 2.9, 1.4, 4.5, 3.3, and 14.3%, respectively. Intermediate-high risk PE occurs in approximately one-tenth of patients with acute symptomatic PE, and is associated with high morbidity and mortality. Normalization of HR 48 hours after diagnosis might identify a group of patients with a very low risk of deterioration during the first month of follow-up.

Highlights

For normotensive patients diagnosed with pulmonary embolism (PE), risk stratification should aim to identify the group of patients deemed as having a high risk for a PE-related complicated course that might benefit from intensive monitoring or escalation of therapy.[4]
According to the European Society of Cardiology (ESC) guidelines, normotensive PE patients with a positive prognostic score (i.e., Pulmonary Embolism Severity Index [PESI], simplified PESI [simplified Pulmonary Embolism Severity Index (sPESI)]), and evidence of right ventricle (RV) dysfunction by elevated cardiac biomarkers and imaging should be classified into an intermediate-high risk category.[4]
The sensitivity, specificity, and predictive values for the tests performed at 48 hours for predicting 30-day adverse events are listed in ►Table 3. In this prospective cohort study, intermediate-high risk PE occurred in 10% of normotensive patients with acute symptomatic PE, with markedly worse outcomes compared with those with low- or intermediate-low risk PE

Summary

Introduction

Unstable acute pulmonary embolism (PE) is a cardiovascular emergency, associated with high risk of death from worsening right ventricle (RV) failure and cardiogenic/obstructive shock, with an in-hospital mortality rate of > 15%.1–3 For normotensive patients diagnosed with PE, risk stratification should aim to identify the group of patients deemed as having a high risk for a PE-related complicated course (intermediate-high risk PE) that might benefit from intensive monitoring or escalation of therapy.[4]Prior investigations from existing PE registries have provided some important insights into the use of prognostic tools to identify patients with intermediate-high risk PE.[5,6] According to the European Society of Cardiology (ESC) guidelines, normotensive PE patients with a positive prognostic score (i.e., Pulmonary Embolism Severity Index [PESI], simplified PESI [sPESI]), and evidence of RV dysfunction by elevated cardiac biomarkers (i.e., cardiac troponin test) and imaging should be classified into an intermediate-high risk category.[4]. Unstable acute pulmonary embolism (PE) is a cardiovascular emergency, associated with high risk of death from worsening right ventricle (RV) failure and cardiogenic/obstructive shock, with an in-hospital mortality rate of > 15%.1–3. For normotensive patients diagnosed with PE, risk stratification should aim to identify the group of patients deemed as having a high risk for a PE-related complicated course (intermediate-high risk PE) that might benefit from intensive monitoring or escalation of therapy.[4]. There is uncertainty about the subgroup of patients with intermediate-high risk PE who are more likely to deteriorate, and may benefit from reperfusion

Methods

Results

Conclusion