Intermediate-High Risk Pulmonary Embolism

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.

Keywords

pulmonary embolism - intermediate-high risk - survival - prognosis

Authors' Contributions

Study concept and design: R.M., B.B., D.J.

Acquisition of data; analysis and interpretation of data; statistical analysis: R.M., F.L., B.B., R.M., D.B., E.M., L.M., V.T., R.D.Y., D.J.

Critical revision of the manuscript for important intellectual content: R.M., F.L., B.B., R.M., D.B., E.M., L.M., V.T., R.D.Y., D.J.

Study supervision: B.B., D.J.

D.J. has full access to all the data in the study and takes the final responsibility of the decision of submitting the manuscript for publication.

^* These authors contributed equally to the manuscript.

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