Prognostic Significance of Deep Vein Thrombosis in Patients Presenting with Acute Symptomatic Pulmonary Embolism

Abstract

Conclusion: In patients with an acute symptomatic pulmonary embolism (PE), a concurrent diagnosis of deep venous thrombosis (DVT) is an independent predictor of increased risk of death within 3 months after the PE diagnosis. Summary: The 3-month mortality rates after an objectively confirmed diagnosis of acute PE vary from 1.4% to 17.4%. Variability in mortality likely illustrates differences in the clinical spectrum of patients with PE. Early deaths in patients with PE are secondary to PE-associated complications. Underlying medical problems cause most late deaths (Conget F, et al; Thromb Haemost 2008;100:937-42). Up to 61% of patients with acute PE have concomitant DVT (Bradley MJ, et al; Clin Radiol 1995;50:232-4). The significance of finding DVT and PE at the time of presentation of PE is debated. Some studies note that diagnosis of proximal DVT is an independent predictor of adverse outcome. Other studies have not confirmed these findings (Wicki J, et al; Thromb Haemost 2000;84:548-52 and Girard P et al; Chest 2005;128:1593-600). This study aimed to assess the association between a concurrent diagnosis of DVT and PE on risk of death in patients with a first objectively confirmed diagnosis of acute symptomatic PE. The primary end point of this prospective cohort study of outpatients was all cause mortality, and the secondary outcome was PE-specific death in the first 3 months after the PE diagnosis. PE was diagnosed in 707 patients, and DVT was also diagnosed in 362 (51.2%); 77 patients (10.9%) died during follow-up. Patients with concurrent DVT had increased all-cause mortality (adjusted HR, 2.05; 95% CI, 1.24-3.38, P = .005) and increased PE-specific mortality (adjusted HR 4.25; 95% CI, 1.61-11.25, P = .04). An external validation cohort of 4476 patients with acute PE enrolled in the RIETE registry also determined a concurrent DVT diagnosed at the time of PE was a significant predictor of all-cause (adjusted HR, 1.66; 95% CI, 1.28-2.15; P < .001) and PE-specific mortality (HR, 2.01; 95% CI, 1.18-3.44, P = .01). Comment: These data provide evidence that a first episode of acute symptomatic PE with a concurrent diagnosis of DVT imparts increased risk of all-cause and PE-specific death in the first 3 months after a diagnosis of PE. Although some may argue that a patient with a diagnosed PE does not need investigation for lower extremity DVT because the PE is going to be treated with anticoagulation anyway, the data imply patients with PE should undergo investigation for DVT for prognostic purposes and risk stratification. Such studies may identify patients at high risk of early death who may benefit from more intensive surveillance or aggressive therapy.