Pulmonary Embolism Mortality Research Articles

5-year outcomes of pulmonary embolism patients according to symptoms at 6-month: the QOLAPE study

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): CHU Toulouse Rangueil Background Venous thromboembolic disease is a common cardiovascular disease, but long-term data on patient survival according to mid-term symptoms are scarce. Objective To describe outcomes (mortality and functional status) of pulmonary embolism (PE) 5 years after a first inaugural symptomatic episode of acute PE according to symptoms persistence at 6-months. Methods 137 patients with acute symptomatic PE were consecutively recruited at a French University Hospital from 2015 to 2017. Clinical characteristics were compared at 5-years between patients with persistent respiratory symptoms and asymptomatic patients at 6-month. Telephone collection of vital status, recurrence of VTE, NYHA score, current treatment, bleeding events as well as follow-up provided by a specialist were carried out in March 2022 on 105 patients (11% were lost of follow up). Results Patients were predominantly male (n=63, 57.5%) 60.2 yo. PE was initially classified at low, intermediate low, intermediate high and high risk respectively in 42.8, 25.7, 30.5 and 1%. 60 patients (57%) were symptomatics at 6 months. At 5 years, survival was 87.1% with a 17.7% recurrence rate regardless of initial PE presentation and severity, and 50% of patients remain symptomatic. Age, hypertension, diabetes, renal failure, obesity and the existence of a psychiatric pathology are associated with a higher mortality at 5 years. The survival and recurrence of MTVE at 5 years are similar between symptomatic or asymptomatic status at 6 months but symptomatic patients at 6 months are twice as many symptomatic at 5 years than asymptomatic patients at 6 months. Conclusion After an inaugural acute symptomatic PE is 5-year survival was 87%. Age, obesity, diabetes, renal failure, hypertension and the existence of an underlying psychiatric pathology are associated with a poorer prognosis at 5 years. The persistence of symptoms at 6 months of PE was not correlated with survival or recurrence of VTE at 5 years but at the persistence of symptoms at 5 years.

Clinical importance of red cell distribution width and red cell index in pulmonary embolism.

Discrimination of high mortality risk pulmonary embolism (PE) patients at the first admission to the hospital is important for the follow-up and the clinical progress of patients. Additional biomarkers are needed for the initial assessment. The aim of this study was to investigate whether red cell distribution width (RDW) and red cell index (RCI) were associated with 30-day mortality risk and mortality rate in PE patients. 101 PE patients and 92 non-PE patients were included in the study. PE patients were divided into three groups according to 30-day mortality risk. The correlations of RDW and RCI with PE, 30-day mortality risk and mortality rates were determined. RDW value was significantly higher in the PE group than in the non-PE group (15.0 % vs. 14.3%, respectively, p=0.016). The cut-off value of RDW to discriminate PE from the non-PE group was 14.55% (sensitivity: 45.7%; specificity: 55.5%, p=0.016). There was a significant correlation between RDW values and mortality rates (R2= 0.11, p=0.001). The cut-off value of RDW in mortality of PE was 15.05% (sensitivity: 40.6%, specificity: 31.2%, p=0.001). On the other hand, simultaneously measured RCI values were similar between PE and non-PE groups. There wasn't any significant difference in RCI values between 30 day-mortality risk groups. No correlation was found between RCI and the mortality due to PE. To the best of our knowledge, this is the first report in the literature to simultaneously investigate RDW and RCI values for their association with 30-day mortality risk and mortality rates in pulmonary embolism (PE) patients. Our findings suggest that RDW values may serve as a new early predictor, while RCI values were not predictive.

CT-defined pectoralis muscle mass and muscle density are associated with mortality in acute pulmonary embolism. A multicenter analysis

Computed tomography (CT) defined muscle mass can be used as a surrogate parameter for sarcopenia. The present study used thoracic CT to assess pectoralis muscle area and density as an imaging biomarker for prognosis of 30-day mortality in patients with acute pulmonary embolism (PE) METHODS: The clinical database was retrospectively screened for patients with thoracic CT in 3 centers. Pectoralis musculature was measured on axial slices of the thoracic CT at the level of T4 of contrast enhanced pulmonary angiography CT. Skeletal muscle area (SMA), skeletal muscle index (SMI), muscle density and gauge were calculated. Overall, 981 patients (440 female, 44.9%) with a mean age of 63.5±15.9 years were included into the study and 144 patients (14.6%) died within the 30-days period. Every pectoral muscle value was higher in survivors compared to non-survivors (exemplarily for SMI 9.9±3.5cm2/m2 versus 7.8±2.6cm2/m2, p<0.001). Moreover, 91 patients were defined as hemodynamically instable (9.3%). Comparable, every pectoral muscle parameter was higher in patients with hemodynamically stable course compared to instable course. Different muscle variables are related to 30-day mortality: SMA, OR=0.94 (95%CI= (0.92; 0.96), p<0.001); SMI, OR=0.78 (95%CI= (0.72; 0.84), p<0.001); muscle density, OR=0.96 (95%CI= (0.94; 0.97), p<0.001); muscle gauge OR=0.96 (95%CI= (0.94; 0.99), p<0.001). SMI and muscle density were independently associated with 30-days mortality: SMI, OR=0.81 (95%CI= (0.75; 0.88), p<0.001); muscle density: OR=0.96 (95%CI= (0.95; 0.98), p<0.001). Parameters of the pectoralis musculature are associated with 30-day mortality in patients with acute PE. These findings should lead to an independent validation study and ultimately to the inclusion into clinical routine as a prognostic factor.

Treatment And Prevention of Deep Vein Thrombosis

Deep vein thrombosis (DVT) is caused by abnormal deep vein coagulation, which is most common in the lower limbs, but sometimes it may also occur in other parts such as the subclavian vein. The main adverse consequence of DVT is pulmonary embolism (PE), which will seriously affect the quality of life of patients, and even endanger their lives. Although Paget-Schroetter syndrome (PSS) syndrome is rare, it also affects the physical and mental health of patients to a certain extent. Many factors may lead to the occurrence of this disease. Clinically, more attention should be paid to the risk factors to prevent the occurrence of the disease. At the same time, when the disease occurs, active treatment and intervention should be carried out to delay the progress of the disease. Anticoagulation is the basic treatment of DVT, which can inhibit the spread of thrombus, facilitate the autolysis of thrombus and recanalization of the lumen, and reduce the incidence and mortality of PE. At the same time, combined with other treatment programs, co-intervention.

Right ventricular area predicts short-term mortality in acute pulmonary embolism based on CT pulmonary angiography: A retrospective study.

We performed this cohort study to assess the prognostic value of right ventricular size, including diameter, area, and volume, in short-term mortality of acute pulmonary embolism (APE) based on 256-slice computed tomography compared with D-dimer, creatine kinase muscle and brain isoenzyme, and Wells scores. A total of 225 patients with APE, who were followed up for 30 days were enrolled in this cohort study. Clinical data, laboratory indices (creatine kinase, creatine kinase muscle and brain isoenzyme, and D-dimer), and Wells scores were collected. The 256-slice computed tomography was used to quantify cardiac parameters (RVV/LVV, RVD/LVD-ax, RVA/LVA-ax, RVD/LVD-4ch, RVA/LVA-4ch) and the diameter of the coronary sinus. Participants were divided into non-death and death groups. The values mentioned above were compared between the 2 groups. The RVD/LVD-ax, RVA/LVA-ax, RVA/LVA-4ch, RVV/LVV, D-dimer, and creatine kinase levels were significantly higher in the death group than in the non-death group (P < .05). The active period of the malignant tumor, heart rate ≥ 100 beats/minutes, and RVA/LVA-ax were positively correlated with early death from APE (P < .05). Active stage of malignant tumor (OR:9.247, 95%CI:2.682-31.888, P < .001) and RVA/LVA-ax (OR:3.073, 95%CI:1.447-6.528, P = .003) were independent predictors of early death due to APE. According to the receiver operating characteristic curve, the cutoff point of RVA/LVA-ax was 1.68 with a sensitivity of 46.7% and specificity of 84.8%. The measurement of ventricular size in the short-axis plane is more convenient and reliable than that in the 4-chamber cardiac plane. RVA/LVA-ax is an independent predictor of early death from APE, and when RVA/LVA-ax > 1.68, the risk of early death from APE increases.

Social determinants of health in pulmonary embolism management and outcome in hospitals: Insights from the United States nationwide inpatient sample

BackgroundThe role of social determinants in the treatment and course of acute pulmonary embolism (PE) is understudied. ObjectiveTo investigate the association between social determinants of health with in-hospital management and early clinical outcomes following acute PE. MethodsWe identified hospitalizations of adults with acute PE discharge diagnosis from the nationwide inpatient sample (2016-2018). Multivariable regression was used to investigate the association between race/ethnicity, type of expected primary payer, and income with the use of advanced PE therapies (thrombolysis, catheter-directed treatment, surgical embolectomy, extracorporeal membrane oxygenation), length of stay, hospitalization charges, and in-hospital death. ResultsA total of 1,124,204 hospitalizations with a PE diagnosis were estimated from the 2016–2018 nationwide inpatient sample, corresponding to a hospitalization rate of 14.9/10,000 adult persons-year. The use of advanced therapies was lower in Black and Asian/Pacific Islander (vs. White patients: adjusted odds ratio [ORadjusted], 0.87; 95% confidence interval [CI], 0.81–0.92 and ORadjusted 0.76; 95% CI, 0.59–0.98) and in Medicare- or Medicaid-insured (vs. privately-insured; ORadjusted, 0.73; 95% CI, 0.69–0.77 and ORadjusted, 0.68; 95% CI, 0.63–0.74), although they had the greatest length of stay and hospitalization charges. In-hospital mortality was higher in the lowest income quartile (vs. highest quartile; ORadjusted, 1.09; 95% CI, 1.02–1.17). Among high-risk PE, patients of other than the White race had the highest in-hospital mortality. ConclusionWe observed inequalities in advanced therapies used for acute PE and higher in-hospital mortality in races other than White. Low socioeconomic status was also associated with lesser use of advanced treatment modalities and greater in-hospital mortality. Future studies should further explore and consider the long-term impact of social inequities in PE management.

Association of intermittent or continuous androgen deprivation therapy with cardiovascular disease and endocrine/metabolic disorders in patients with nonmetastatic prostate cancer.

83 Background: Evidence on risks of cardiovascular disease (CVD) and endocrine/metabolic disorders associated with long-term intermittent and continuous androgen deprivation therapy (iADT and cADT, respectively) in patients (pts) with nonmetastatic prostate cancer (nmPC) is mixed. This real-world study examined these risks in pts with nmPC receiving iADT or cADT in the US. Methods: This was a retrospective cohort study of SEER-Medicare pts with nmPC initiating ADT (2010–2017), with ≥36 months of continuous insurance coverage, unless death occurred, and who did not receive chemotherapy or a second-generation anti-androgen during follow-up. iADT and cADT cohorts were defined by treatment patterns and gaps in therapy. Comorbidities and clinical events were identified using ICD-9/10-CM codes. Outcomes examined were major adverse cardiovascular events (MACE [myocardial infarction (MI), stroke, cardiomyopathy/heart failure (HF), pulmonary embolism (PE), ischemic heart disease (IHD), or all-cause mortality]) and endocrine/metabolic events (diabetes, hypercholesterolemia, bone fractures, or osteoporosis). Inverse probability of treatment-weighted Cox regression models estimated the adjusted hazard ratio (aHR) of the outcomes. Subgroup analyses examined pts by CVD history. A sensitivity analysis restricted the definition of MACE to include CVD-related mortality as a component, i.e., MACESA (MI, stroke, cardiomyopathy/HF, PE, IHD, or CVD-related mortality). Results: 10,655 pts were included; 2095 (20%) received iADT and 8560 (80%) cADT; 63% of iADT pts and 66% of cADT pts had baseline CVD history. Median follow-up was 44 and 48 months and time on ADT (excluding gaps for iADT pts) was 23 and 17 months for the iADT and cADT cohorts, respectively. In adjusted analyses, pts receiving cADT had a lower risk of MACE vs iADT. No difference in risk of endocrine/metabolic events was observed. Results for MACE were similar in pts with prior CVD history; however, there was no difference in risk of MACE in those without CVD history. Sensitivity analysis results for MACESA were similar to the main results. Conclusions: Pts with nmPC receiving cADT had a lower risk of MACE, and no difference in risk of endocrine/metabolic events, compared with iADT. There was no difference in risk of MACE in pts without a prior history of CVD. [Table: see text]

Association of intermittent vs continuous androgen deprivation therapy with cardiovascular disease and endocrine/metabolic disorders in patients with metastatic prostate cancer.

82 Background: There is mixed evidence on the risks of cardiovascular disease (CVD) and endocrine/metabolic disorders associated with long-term intermittent and continuous androgen deprivation therapy (iADT and cADT, respectively) for metastatic prostate cancer (mPC). This study examined these risks in patients (pts) with mPC receiving iADT vs cADT in the US. Methods: This was a retrospective cohort study of SEER-Medicare pts with mPC initiating ADT (2010–2017), with ≥36 months of continuous insurance coverage, unless death occurred, who did not receive chemotherapy or a second-generation anti-androgen during follow-up. iADT and cADT cohorts were defined by treatment patterns and gaps in therapy. Comorbidities and clinical events were identified using ICD-9/10-CM codes. Outcomes examined were major adverse cardiovascular events (MACE [myocardial infarction (MI), stroke, cardiomyopathy/heart failure (HF), pulmonary embolism (PE), ischemic heart disease (IHD), or all-cause mortality]) and endocrine/metabolic events (diabetes, hypercholesterolemia, bone fractures, or osteoporosis). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between cohorts; weighted Cox models were used to estimate the hazard ratio (HR) of the outcomes. Subgroup analyses examined pts by CVD history; a sensitivity analysis was performed restricting the definition of MACE to include CVD-related mortality as a component, i.e., MACESA (MI, stroke, cardiomyopathy/HF, PE, IHD, or CVD-related mortality). Results: 2234 pts with mPC were included; 478 (21%) received iADT and 1756 (79%) cADT. Median follow-up time was 27 and 13 months, and time on ADT (excluding gaps for iADT pts) was 24 and 19 months for the iADT and cADT cohorts, respectively. Deaths occurred in 39% of iADT pts vs 55% of cADT pts; PC was the most common cause of death in both cohorts. In adjusted analyses, pts receiving cADT had a higher risk of MACE vs iADT. No differences in risk of endocrine/metabolic events were observed. Subgroup analysis showed that baseline history of CVD did not alter the results for MACE. Sensitivity analysis results showed no difference in risk of MACESA between pts receiving cADT vs iADT. Conclusions: Pts with mPC receiving cADT had a higher risk of MACE (including all-cause mortality), and no difference in risk of endocrine/metabolic events, compared with those receiving iADT. When MACE was restricted to include CVD-related mortality, there was no difference in risk between cohorts. [Table: see text]

Computed Tomography Angiography for Detection of Pulmonary Embolism in Western Australia Shows Increasing Use with Decreasing Diagnostic Yield.

(1) Background: Pulmonary embolism (PE) can be fatal. Computed tomography pulmonary angiography (CTPA) can accurately diagnose PE, but it should be used only when reasonable pre-test probability exists. Overtesting with CTPA exposes patients to excess ionizing radiation and contrast media, while PE overdiagnosis leads to the treatment of small emboli unlikely to cause harm. This study assessed trends in CTPA use and diagnostic yield. We also assessed trends in PE hospitalizations and mortality to indicate PE severity. (2) Methods: Analysis of Western Australian linked administrative data for 2003-2015 including hospitalizations, emergency department (ED) attendances, and CTPA performed at hospitals. Age-sex standardized trends were calculated for CTPA use, PE hospitalizations, and mortality (as a proxy for severity). Logistic regression assessed diagnostic yield of CTPA following unplanned ED presentations. (3) Results: CTPA use increased from 3.3 per 10,000 person-years in 2003 (95% CI 3.0-3.6) to 17.1 per 10,000 person-years (16.5-17.7) in 2015. Diagnostic yield of CTPA increased from 12.7% in 2003 to 17.4% in 2005, declining to 12.2% in 2015 (p = 0.049). PE hospitalizations increased from 3.8 per 10,000 (3.5-4.1) in 2003 to 5.2 per 10,000 (4.8-5.5) in 2015. Mortality remained constant at 0.50 per 10,000 (0.39-0.62) in 2003 and 0.42 per 10,000 (0.32-0.51) in 2015. (4) Conclusions: CTPA increased from 2003 to 2015, while diagnostic yield decreased, potentially indicating overtesting. PE mortality remained constant despite increasing hospitalizations, likely indicating a higher proportion of less severe cases. As treatment can be harmful, this could represent overdiagnosis.

Analysis of contemporary mortality trends in pulmonary embolism, United States, 1999–2020

BackgroundA contemporary and comprehensive examination of mortality trends in pulmonary embolism (PE) is needed for the United States (US), as previous studies were either based on preceding data or limited to specific demographic subgroups. We aimed to assess the trends in PE deaths by age, sex, race/ethnicity, and census region in the US from 1999 through 2020. MethodsWe analyzed national mortality data using the CDC WONDER database. PE deaths were identified using the ICD-10 Code- I-26. Age adjusted mortality rates (AAMR) were abstracted by age, sex, race/ethnicity, and census region. Temporal trends were assessed using five-year moving averages and Joinpoint regression models. Annual percentage changes (APC) in AAMR were estimated using Monte Carlo Permutation, and 95 % confidence intervals using the Parametric Method. ResultsOverall mortality trends have stabilized since 2009 (APC = 0.6; 95 % CI: −0.3, 1.6), as were trends among Non-Hispanic Whites (APC = 0.6; 95 % CI: −0.2, 1.4), Non-Hispanic Blacks (APC = 0.7; 95 % CI: −0.2, 1.6), and Hispanics (APC = 1.4; 95 % CI: −0.7, 3.6). AAMR declined by 1.7 % per year (95 % CI: −2.8, −0.7) among Asians/Pacific Islanders and by 1.4 % per year (95 % CI: −2.8, −0.0) among American Indians/Alaska Natives, from 1999 to 2020. Contemporary trends have increased among males (APC = 1.0; 95 % CI: 0.2, 1.9), persons below 65 years of age (APC = 18.6; 95 % CI: 18.6, 18.6; APC = 2.3; 95 % CI: 1.4, 3.1), and persons from the Northeastern (APC = 1.0; 95 % CI: 0.1, 2.0) and Western regions (APC = 1.6; 95 % CI: 0.7, 2.6). ConclusionsThe decline in PE mortality recorded from 1999 through the mid-2000s has not been sustained in the last decade-overall trends have stabilized since 2009. However, there were differences by age, sex, race/ethnicity, and the US census region, with some subgroups demonstrating stationary, increasing, or declining trends. Further studies should examine the drivers of differential trends in the US population to inform evidence-based and culturally competent public health intervention efforts.

The association between glycemia and clinical outcomes in patients with diabetes mellitus and pulmonary thromboembolism.

Various studies have shown that diabetes mellitus (DM) increases the risk of thrombosis in the venous system as well as in the arterial system. In this study, it was aimed to evaluate the association between admission blood glucose levels and clinical severity, recurrence, and mortality in pulmonary embolism in patients with DM. This study was designed as a retrospective cross-sectional study. Patients with DM who were admitted to a tertiary care hospital due to pulmonary embolism (PE) between 2014 and 2019 were included. Demographic characteristics, radiological findings, clinical class of embolism, and mortality data were retrieved from hospital records. Patients with and without recurrent disease, as well as patients who survived and died, were compared. Also, patients were classified according to quartiles of admission blood glucose levels. The quartiles were compared in terms of mortality, clinical, class, and recurrence. Two hundred ninety-three patients with DM and PE were included in the study. Patients with adverse outcome had significantly higher admission blood glucose levels (respectively, 197.9 ± 96.30 mg/dL vs. 170.7 ± 74.26 mg/dL; p = 0.03). Patients in the third and fourth quartile of admission blood glucose levels (>152 mg/ dL) had significantly more severe disease with a higher proportion of massive and sub-massive PE and higher pro-BNP levels (respectively, p = 0.01 and 0.02). Non-survived patients and recurrent disease were associated with higher admission blood glucose levels. Also, patients with admission blood glucose levels higher than 152 mg/dL tend to have clinically more severe diseases.

Deep Learning Analysis of Chest Radiographs to Triage Patients with Acute Chest Pain Syndrome.

Background Patients presenting to the emergency department (ED) with acute chest pain (ACP) syndrome undergo additional testing to exclude acute coronary syndrome (ACS), pulmonary embolism (PE), or aortic dissection (AD), often yielding negative results. Purpose To assess whether deep learning (DL) analysis of the initial chest radiograph may help triage patients with ACP syndrome more efficiently. Materials and Methods This retrospective study used electronic health records of patients with ACP syndrome at presentation who underwent a combination of chest radiography and additional cardiovascular or pulmonary imaging or stress tests at two hospitals (Massachusetts General Hospital [MGH], Brigham and Women's Hospital [BWH]) between January 2005 and December 2015. A DL model was trained on 23 005 patients from MGH to predict a 30-day composite end point of ACS, PE, AD, and all-cause mortality based on chest radiographs. Area under the receiver operating characteristic curve (AUC) was used to compare performance between models (model 1: age + sex; model 2: model 1 + conventional troponin or d-dimer positivity; model 3: model 2 + DL predictions) in internal and external test sets from MGH and BWH, respectively. Results At MGH, 5750 patients (mean age, 59 years ± 17 [SD]; 3329 men, 2421 women) were evaluated. Model 3, which included DL predictions, significantly improved discrimination of those with the composite outcome compared with models 2 and 1 (AUC, 0.85 [95% CI: 0.84, 0.86] vs 0.76 [95% CI: 0.74, 0.77] vs 0.62 [95% CI: 0.60 0.64], respectively; P < .001 for all). When using a sensitivity threshold of 99%, 14% (813 of 5750) of patients could be deferred from cardiovascular or pulmonary testing for differential diagnosis of ACP syndrome using model 3 compared with 2% (98 of 5750) of patients using model 2 (P < .001). Model 3 maintained its diagnostic performance in different age, sex, race, and ethnicity groups. In external validation at BWH (22 764 patients; mean age, 57 years ± 17; 11 470 women), trends were similar and improved after fine tuning. Conclusion Deep learning analysis of chest radiographs may facilitate more efficient triage of patients with acute chest pain syndrome in the emergency department. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Goo in this issue.

Evaluation of the Relationship between FeNO and Clinical Risk Stratification for Early Mortality in Pulmonary Embolism.

Pulmonary embolism (PE) is a common complication of deep vein thrombosis that causes high mortality and morbidity. This study aimed to determine the relationship between clinical risk scoring for early mortality and fractional exhaled nitric oxide (FeNO) in PE patients. The study included a total of 98 subjects, 68 patients diagnosed with PE in the emergency department, and 30 healthy controls. Patients with PE were grouped according to clinical scoring of early mortality risk as low (n = 20), moderate-low (n = 24), and moderate-high (n = 24) risk. FeNO levels were measured after diagnosis. FeNO levels were significantly higher in patients with moderate-high risk PE compared to the other three groups and in those with moderate-low risk PE compared to the control group (p < 0.001 for all). Moderate to strong positive correlations were observed between FeNO level and mean pulmonary artery pressure (r = 0.818, p = 0.01), troponin-I (r = 0.67, p = 0.01), pro-BNP (r = 0.762, p = 0.01), and D-dimer levels (r = 0.652, p = 0.01). A FeNO cutoff value of 7.5 ppb had 84% sensitivity and 78% specificity in differentiating moderate-high risk PE from moderate-low risk PE. FeNO may be as reliable, noninvasive, and easily accessible as cardiac biomarkers in clinical risk scoring for early mortality in PE patients.

Incidentally Diagnosed With Pulmonary Embolism in Lung Cancer Patients: Comparison of Clinical Characteristics and Mortality With Symptomatic Pulmonary Embolism.

The purpose of this work was to compare the clinical characteristics, rate of recurrent venous thromboembolism (VTE), bleeding complications and mortality of incidental and symptomatic pulmonary embolism (PE) detected on computed tomography in patients with lung cancer. Clinical data of lung cancer patients with PE were obtained from the Department of Respiratory and Critical Care Medicine of Ningbo First affiliated hospital of Ningbo University during January 2016 and June 2021 and were reviewed retrospectively. We compared clinical and radiological characteristics in lung cancer patients with incidental PE (IPE) and symptomatic PE (SPE) and identified variables associated with the 1-year survival on multivariate Cox analysis. All patients were followed up for 1 year to compare the risks of recurrent VTE, bleeding complications, and mortality. Survival analysis was performed by use of Kaplan-Meier. A total of 223 lung cancer patients with PE were enrolled over the period. Of these, 117 (52%) patients had symptomatic whereas 106 (48%) patients had incidental PE. Those with IPE were more likely to have adenocarcinoma, VTE history, chronic respiratory disease and chemotherapy within 30 days prior to PE, while SPE was more frequently observed in patients with squamous cancer, concomitant VTE, performance status 0-1, chronic heart disease and major surgery within 30 days prior to PE. During 1 year of follow-up, recurrent VTE was diagnosed in 10 patients (9.3%) in lung cancer patients with IPE and 13 patients (11.2%) with SPE. The 12-month cumulative recurrent VTE incidence was 9.6% for patients with incidental and 11.4% for patients with symptomatic PE (P = .61). The 12-month cumulative incidences of major bleeding complications were also comparable in the 2 groups (8.1% for incidental patients and 9.8% for symptomatic patients; P = .62). However, the respective 12-month mortality risks were 34.6% and 30.2% in lung cancer patients with IPE and SPE respectively (P = .03). On multivariate Cox analysis, we found that IPE occurrence was an independent risk factor associated with 1-year mortality in lung cancer patients complicated with PE after adjusting for age and sex (HR 1.517; 95% CI: 1.366-1.684; P = .027). Our findings suggest that lung cancer patients diagnosed with and treated for incidental PE had a similar rate of recurrent VTE, and incidence of hemorrhagic complications, but a significantly higher 1-year cumulative mortality rate after PE compared to those with symptomatic PE. IPE may be a marker of poor prognosis.

Incidence of Mortality and Complications in High-Risk Pulmonary Embolism: A Systematic Review and Meta-Analysis.

The relationship between the early hemodynamic consequences of acute pulmonary embolism (PE) and short-term morbidity and mortality has long been recognized. The mortality incidence and other complications after high-risk (massive) PE, the most severe category of the disease, are summarized in this meta-analysis. A systematic review and meta-analysis of studies reporting on patients with massive PE indexed by PubMed and the Cochrane Library over a 10-year period (2010-2020) was conducted. Studies with adequate information to specify a cohort of patients with high-risk PE defined by the American Heart Association and European Society of Cardiology criteria and their clinical outcomes were included. Incidences were calculated as weighted averages with 95% CIs. A total of 27 publications spanning 1517 patients were identified that met the search criteria for high-risk PE. In-hospital all-cause mortality averaged 28.3% (95% CI, 20.9%-37.0%) in patients at high risk, comparable to the 30-day all-cause mortality of 30.2% (95% CI, 22.3%-39.6%). In-hospital major bleeding was 13.8% (95% CI, 9.3%-20.0%), and intracranial hemorrhage was reported in 3.6% (95% CI, 2.2%-5.9%). The risk of bias in publications was graded as low-to-moderate, with substantial heterogeneity among the studies. This systematic review and meta-analysis provided low-quality to moderate-quality evidence documenting mortality, major bleeding, and other complications in patients meeting the American Heart Association and European Society of Cardiology criteria for high-risk PE. This information was used to inform the design of the FLowTriever for Acute Massive Pulmonary Embolism (FLAME) study (NCT04795167), a study evaluating an advanced therapy for patients with high-risk PE.

PS-C06-9: THE PREDICTIVE VALUE OF RED CELL DISTRIBUTION WIDTH IN VENOUS THROMBOEMBOLISM AND RELATED MORTALITY

Background: Red cell distribution width (RDW) is a measure of red blood cell size variation and heterogeneity. Recent meta-analyses demonstrated this measurement could be strong predictor in coronary artery disease, chronic heart failure, and atrial fibrillation. Nevertheless, there is no meta-analysis evaluating the role of RDW in prediction of the occurrence of venous thromboembolism (VTE), the third most common cardiovascular disease, and related mortality. Objective: To investigate the association of RDW and VTE including deep vein thrombosis (DVT) and pulmonary embolism (PE) and related mortality. Methods: Major medical databases were systematically searched for observational studies which assessed the association of RDW and VTE published until May 2022. The databases were searched with predefined protocol without language restriction based on PRISMA guidelines. The analysis was performed in RevMan 5.3 to provide pooled measures for Risk Ratio (RR) and weighted mean difference (WMD). Results: Twenty-three studies were enrolled including 6,737 cases and 58,831 controls. Higher RDW was indicated as independent predictors for VTE compared to lower RDW (RR = 1.82, p &lt; 0.00001), comprising DVT and PE (RR = 1.6, p &lt; 0.00001, and RR = 2.05, p = 0.002, respectively). There was also an association between higher RDW and risk of mortality after PE episode with RR = 1.4 (p = 0.0004), involving short- (30-day) and long-term (&gt; 1 year) mortality (RR = 1.79, p = 0.04, and RR = 1.15,p = 0.03, respectively). Compared to lower RDW, higher RDW also revealed a significant association with unprovoked VTE (RR = 2.18, p = 0.02). VTE-group had a higher mean of RDW compared to control with WMD = 1.13% (p &lt; 0.00001), consisting of PE-group (WMD = 0.99%, p &lt; 0.00001) and DVT-group (WMD = 1.07%, p &lt; 0.00001). Among PE patients, The PE-related mortality group also had a higher mean of RDW in comparison to the survivor group with WMD = 1.97%, (p &lt; 0.00001). Conclusions: Higher RDW value was associated with the occurrence of VTE, including DVT, PE, unprovoked VTE, and PE-related mortality. Therefore, the use of the potential role of RDW should be emphasized since it is low-cost and simple to obtain, even in a low-resource setting.

148: HIGH PREVALENCE OF ELEVATED LACTATE IN PULMONARY EMBOLISM PATIENTS WITH LOW-RISK SPESI SCORES

Introduction: Elevated lactate, a possible early marker of hemodynamic collapse, is associated with high 30-day mortality in pulmonary embolism (PE) patients. However, lactate is not included in common PE risk stratification schemes such as the simplified Pulmonary Embolism Severity Index (sPESI). The objective of this study is to assess the prevalence of elevated lactate by sPESI score in PE patients who were undergoing mechanical thrombectomy with the FlowTriever System (Inari Medical). Methods: FLASH is a prospective, multi-center registry assessing FlowTriever mechanical thrombectomy outcomes in PE. FLASH patients were risk-stratified using various methods including sPESI. Lactate was measured pre-thrombectomy, and patients were grouped into normal (< 2 mM) and elevated lactate (≥2 mM). On-table hemodynamics and 30-day safety and mortality outcomes were assessed by lactate group. Results: Lactate measurements were available in 186 patients: 110 (59%) had normal and 76 (41%) had elevated lactate. Mean sPESI scores did not differentiate between those with normal and elevated lactate (1.7±1.1 vs. 1.9±1.2; p=0.171). There was a high prevalence of elevated lactate in patients classified as low-risk: 30% (6/20) of patients with sPESI scores of 0 had elevated lactate. Mechanical thrombectomy resulted in significant on-table improvements in mean PA pressure in patients with normal lactate (31.0±8.3 to 24.1±8.4 mmHg; p< 0.0001) as well as elevated lactate (33.5±9.6 to 25.8±9.2 mmHg; p< 0.0001). Major adverse events through 48 hours occurred in no patients with normal lactate and in 3 (3.9%) with elevated lactate. Post-procedure ICU stays were short overall: median 0.0 days [IQR: 0.0-1.0] in the normal lactate group and 0.5 days [IQR: 0.0-2.0] in the elevated lactate group. Mortality through 30 days was low regardless of lactate status, occurring in 2 (2.0%) patients with normal lactate and 1 (1.4%) with elevated lactate. Conclusions: PE patients classified as low-risk via sPESI had elevated lactate in 30% of cases, suggesting that additional risk factors for decompensation may be missed. While underutilized, assessment of elevated lactate may enhance common risk stratification tools. In patients with elevated lactate, mechanical thrombectomy resulted in hemodynamic improvements and low 30-day mortality.

Deep vein thrombosis symptoms and 30-day mortality in acute pulmonary embolism

BackgroundIn patients with acute symptomatic pulmonary embolism (PE), the presence of concomitant lower-limb deep vein thrombosis (DVT) has been associated with a higher mortality rate. The prognostic significance of DVT symptoms among these patients remains uncertain. MethodsWe used the RIETE (Registro Informatizado de Enfermedad TromboEmbólica) registry to compare the 30-day mortality rate in patients with PE and concomitant lower-limb DVT, according to the presence or absence of DVT symptoms. Primary outcomes were all-cause death and PE-related death within the first 30 days. ResultsSince March 2001 to June 2021, there were 17,742 patients with acute symptomatic PE and objectively proven concomitant lower-limb DVT. Of these, 11,984 (68%) had DVT symptoms. Most patients with or without DVT symptoms (82% vs. 81%) received low-molecular-weight heparin initially. Then, most (61% vs. 58%) switched to vitamin K antagonists. During the first 30 days of therapy, 497 patients with DVT symptoms (4.1%) and 164 (2.8%) with no DVT symptoms died (rate ratio [RR]: 1.48; 95%CI: 1.23-1.77). The rates of PE-related death were: 1.0% vs. 0.7%, respectively (RR: 1.50; 95%CI: 1.04-2.16). On multivariable analysis, patients with DVT symptoms were at increased risk for all-cause death (adjusted hazard ratio [aHR]: 1.49; 95%CI: 1.24-1.78), and PE-related death (aHR: 1.52; 95%CI: 1.05-2.20). ConclusionAmong patients with acute symptomatic PE and concomitant lower-limb DVT, those with DVT symptoms had an increased all-cause and PE-related mortality within 30 days. Assessment of DVT symptoms would assist with risk stratification of these patients.

Risk factors and mortality of pulmonary embolism in COVID-19 patients: Evidence based on fifty observational studies.

At present, many studies have described acute pulmonary embolism (PE) as a frequent and prognostically relevant complication of coronavirus disease 2019 (COVID-19) infection. Thus we performed the present analysis of 50 studies to evaluate the risk factors and mortality of PE in COVID-19 patients. Databases including PubMed, Embase, Cochrane Library and Web of Science were searched to October, 2021. Odds ratio (OR), mean difference (MD) or standard MD was used to evaluate the outcomes. The primary outcomes were the difference of mortality between PE and non-PE COVID-19 patients as well as relevant risk factors of PE in COVID-19 patients. All statistical analyses were performed using the standard statistical procedures provided in Review Manager 5.2. A total of 50 studies including 10053 patients were included in this meta-analysis. Our results indicated that COVID-19 patients with PE experienced significantly higher mortality than non-PE patients (21.9% vs. 10.7%), with a pooled OR of 2.21 (95% CI 1.30 - 3.76; P = .003). In addition, COVID-19 patients with PE also experienced more mechanical ventilation (MV) (OR 2.21; 95% CI 1.30 - 3.75; P = .003) and invasive mechanical ventilation (IMV) (OR 3.58; 95% CI 2.47 - 5.20; P < .0001) respectively. Univariate analysis (UVA) results indicated the Sequential Organ Failure Assessment (SOFA) score, time to deep venous thrombosis (DVT), nonintensive care unit (non-ICU) patients and no anticoagulation as risk factors of PE for COVID-19 patients. In addition, multivariate analysis also found that SOFA score, D-dimer, BMI > 30 kg/m2 and history of PE were risk factors of PE for COVID-19 patients. The present analysis indicated that PE increased the mortality of COVID-19 patients. Mechanical ventilation, especially invasive mechanical ventilation, is correlated with an increased incidence of PE in patients with COVID-19. The incidence of PE for COVID-19 patients may be multifactorial and further researches focused on risk factors were needed in the future.

Abstract 14648: Can GRACE Risk Score Predict Mortality in Pulmonary Embolism?

Introduction Risk stratifying of pulmonary embolism (PE) patients and treatment for normotensive patients is still challenging. We aimed to assess the utility of GRACE risk score for 30-day mortality. Methods All consecutive patients hospitalized with a diagnosis of PE between2016 -2021 were included in this retrospective study. GRACE and PESI scores were calculated online. Results A total of 197 patients were enrolled. Mean age was 63.98±15.51. 56 of patients died by the end of the 30-day. When patients divided into 2 groups according to 30-day mortality, both groups were similar in terms of gender, hypertension, diabetes mellitus, coronary artery disease, heart failure and chronic obstructive pulmonary disease. Troponin level (212.4± 24.6 vs. 850.8±231.1; p&lt;0.0001), PESI (122.3±27.2 vs. 170.1±49.1; p&lt;0.0001) and GRACE (127.1±28.8 vs. 182±21.3; p&lt;0.0001) were significantly higher in non-survivor group. The correlation analysis we observed strong positive correlation between PESİ and GRACE (r=0.732; p&lt;0.0001). Regression analysis revealed that only GRACE score [p=0.021, β: 1.146, OR (95% CI): 1.021-1.286] was an independent risk factor associated with 30-day mortality. ROC curve for accuracy of GRACE score for predicting 30-day mortality in PE patients is shown in figure 1. Area under curve (AUC) for GRACE score was 0.969 [%95 CI: 0.948-0.990]. A cut off value of 161.5 for GRACE score was associated with 90.0% sensitivity and 89.7% specificity in prediction of 30-day mortality. Conclusion In this study, the relation between GRACE score and the clinical course of PE patients evaluated and we found GRACE risk score as an independent risk factor associated with 30-day mortality and strong correlation between GRACE and PESİ risk scores. To predict the mortality of high-risk normotensive and hypotensive PE patients,GRACE risk score exhibited high specificity and positive probability.