Association of anaemia and mortality in patients with acute pulmonary embolism

David Jiménez; Carlos Escobar; David Martí; Gema Díaz; Jesús César; Ángel García-Avello; Antonio Sueiro; Roger D. Yusen

doi:10.1160/TH09-01-0003

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2009; 102(01): 153-158
DOI: 10.1160/TH09-01-0003

New Technologies, Diagnostic Tools and Drugs

Schattauer GmbH

Association of anaemia and mortality in patients with acute pulmonary embolism

David Jiménez

¹Respiratory Department, Ramón y Cajal Hospital, Madrid, Spain

,

Carlos Escobar

²Cardiology Department, Ramón y Cajal Hospital, Madrid, Spain

,

David Martí

²Cardiology Department, Ramón y Cajal Hospital, Madrid, Spain

,

Gema Díaz

¹Respiratory Department, Ramón y Cajal Hospital, Madrid, Spain

,

Jesús César

³Hematology Department, Ramón y Cajal Hospital, Madrid, Spain

,

Ángel García-Avello

³Hematology Department, Ramón y Cajal Hospital, Madrid, Spain

,

Antonio Sueiro

¹Respiratory Department, Ramón y Cajal Hospital, Madrid, Spain

,

Roger D. Yusen

⁴Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, USA

› Author Affiliations

Abstract

Summary

This study aimed to evaluate the relationship between anaemia and pulmonary embolism (PE) prognosis. We analysed a cohort of 764 patients with acute PE referred to a single center for diagnosis and management. Patients were divided into groups by quartiles of haemoglobin (Hb): Hb < 11.7 g/dl; Hb 11.7 to 12.9 g/dl; Hb 13.0 to 14.1 g/dl; Hb > 14.1 g/dl. Patients had a mean Hb of 12.9 g/dl, and values ranged from to 4.3 to 19.5 g/dl. Lower Hb was associated with recent bleeding, an impaired haemodynamic profile and higher creatinine. Patients in the lower Hb quartiles more commonly had female gender (p < 0.001), a diagnosis of cancer (p < 0.001), and an indication for an inferior vena cava (IVC) filter (p < 0.002), compared to patients in the higher Hb quartiles. Patients in higher Hb quartiles had higher survival at three months (75%, 86%, 90% and 91% for lowest to highest quartiles, respectively). On multivariate analysis, adjusting for known PE prognostic factors, low Hb proved to be an independent predictor of mortality (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.05 to 1.28 for each decrease of 1 g/dl). Hb level remained an independent predictor of all-cause mortality when cancer patients were excluded from the analysis (adjusted HR 0.81; 95% CI, 0.66 to 0.99; p = 0.04). Moreover, patients with anaemia showed a higher risk of fatal PE (unadjusted HR 1.19, 95% CI 1.04 to 1.37). In conclusion, in patients with acute symptomatic PE, anaemia severity is associated with worsened survival.

Keywords

Clinical studies - lung - pulmonary embolism - anaemia - prognosis

Full Text

References

References
1 Konstantinides S. Diagnosis and therapy of pulmonary embolism. VASA 2006; 35: 135-146.
2 Heit JA. Venous thromboembolism: disease burden, outcomes and risk factors. J Thromb Haemost 2005; 03: 1611-1617.
3 Bremberg ER, Brandberg Y, Hising C. et al. Anemia and quality of life including anemia-related symptoms in patients with solid tumors in clinical practice. Med Oncol 2007; 24: 95-102.
4 Bokemeyer C, Aapro MS, Courdi A. et al. EORTC guidelines for the use of erythropoietic proteins in anaemic patients with cancer: 2006 update. Eur J Cancer 2007; 43: 258-270.
5 Bohlius J, Weingart O, Trelle S, Engert A. Cancerrelated anemia and recombinant human erythropoietin-- an updated overview. Nat Clin Pract Oncol 2006; 03: 152-164.
6 Means RT. Pathogenesis of the anemia of chronic disease: a cytokine-mediated anemia. Stem Cells 1995; 13: 32-37.
7 Szachniewicz J, Petruk-Kowalczyk J, Majda J. et al. Anemia is an independent predictor of poor outcome in patients with chronic heart failure. Int J Cardiol 2003; 90: 303-308.
8 Redondo-Bermejo B, Pascual-Figal DA, Hurtado-Martínez JA. et al. Clinical determinants and prognostic value of hemoglobin in hospitalized patients with systolic heart failure. Rev Esp Cardiol 2007; 60: 597-606.
9 Horwich TB, Fonarow GC, Hamilton MA. et al. Anemia is associated with worse symptoms, greater impairment in functional capacity and significant increase in mortality in patients with advanced heart failure. J Am Coll Cardiol 2002; 39: 1789-1786.
10 The PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the Prospective Investigation of Pulmonary Embolism Diagnosis. J Am Med Assoc 1990; 263: 2753-2769.
11 Remy-Jardin M, Remy J, Wattinne L. et al. Central pulmonary thromboembolism: diagnosis with spiral volumetric CT with the single-breathhold-technique-comparison with pulmonary angiography. Radiology 1992; 185: 381-387.
12 World Health Organization. Nutritional anaemias: report of a WHO scientific group. Geneva, Switzerland: World Health Organization; 1968
13 Al-Ahmad A, Rand SM, Manjunath G. et al. Reduced kidney function and anemia as risk factors for mortality in patients with left ventricular dysfunction. J Am Coll Cardiol 2001; 38: 955-962.
14 O’Meara E, Clayton T, McEntegart MB. et al. Clinical correlates and consequences of anemia in a broad spectrum of patients with heart failure: results of the Candesartan in Heart Failure: assessment of reduction in mortality and morbidity (CHARM) program. Circulation 2006; 113: 986-994.
15 Ezekowitz JA, McAlister FA, Armstrong PW. Anemia is common in heart failure and is associated with poor outcomes. Circulation 2003; 107: 223-225.
16 Anand IS, Chandrasehekhar Y, Ferrari R. et al. Pathogenesis of oedema in chronic severe anemia: studies of body water and sodium, renal function, haemodinamic variables, and plasma hormones. Br Heart J 1993; 70: 357-362.
17 Weiskopf RB, Viele MK, Feiner J. et al. Human cardiovascular and metabolic response to acute, severe isovolemic anemia. J Am Med Assoc 1998; 279: 217-221.
18 Conget F, Otero R, Jiménez D. et al. Short-term clinical outcome after acute symptomatic pulmonary embolism. Thromb Haemost 2008; 100: 937-942.
19 Ruiz-Giménez N, Suárez C, González R. et al. >and the RIETE investigators. Predictive variables for major bleeding events in patients presenting with documented acute venous thromboembolism. Findings from the RIETE registry. Thromb Haemost 2008; 100: 26-31.
20 Bentel G, Ganser A. Risks and benefits of erythropoiesis-stimulating agents in cancer management. Semin Hematol 2007; 44: 157-165.
21 Hurter B, Bush NJ. Cancer-related anemia: clinical review and management update. Clin J Oncol Nurse 2007; 11: 349-359.
22 Schwartz RN. Anemia in patients with cancer: incidence, causes, impact, management, and use of treatment guidelines and protocols. Am J Health Syst Pharm 2007; 64: 5-13.
23 Monreal M, Falga C, Valle R. et al. Venous thromboembolism in patients with renal insufficiency: findings from the RIETE registry. Am J Med 2006; 119: 1073-1079.
24 Trujillo-Santos J, Herrera S, Page MA. et al. Predicting adverse outcome in outpatients with acute deep vein thrombosis: findings from the RIETE registry. J Vasc Surg 2006; 44: 789-793.
25 Jiménez D, Díaz G, Molina J. et al. Troponin I and risk stratification of patients with acute non massive pulmonary embolism. Eur Respir J 2008; 31: 847-853.
26 Sanchez O, Trinquart L, Colombet I. et al. Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review. Eur Heart J 2008; 29: 1569-1577.