Pulmonary embolism (PE) represents a disease with disparate outcomes. Despite a paucity of data showing clear benefits, aggressive therapy with thrombolytics and pulmonary thromboembolectomy are accepted treatments in hemodynamically unstable PE (MPE) patients while efficacy data is equally lacking and additionally contentious in stable PE (HS-PE) patients. The current study was designed to examine the relationship between demographic variables, hemodynamic status, time to initial presentation, and treatment modality on PE-related mortality.
Data regarding age, gender, history of pre-existing cardiopulmonary disease (CPD), hemodynamic status within 3 hours of presentation, time from symptom onset to initial evaluation, and treatment modality were collected retrospectively in consecutive patients with diagnostically confirmed PE. Early treatment was defined as time to evaluation 0-6 hours and late as >6 hours. Aggressive care was defined as thrombolysis or embolectomy while heparin therapy, inferior vena cava interruption, or both was considered routine care. Using multivariable logistic regression, the effects of these predictive variables on mortality were examined.
562 patients were included in the final regression model. Overall mortality was 8.5% (513 alive, 48 dead). Adjusted odds ratios and their corresponding 95% CI for each variable are as follows: age 0.997 (0.974-1.020), gender 0.706 (0.336-1.484), CPD 2.614 (1.189-5.747), shock 11.156 (5.226-23.813), early versus late treatment 1.393 (0.643-3.017), aggressive versus routine therapy 4.161 (0.209-82.2922). Only CPD and shock remained significant, both with p-values of < 0.001.
Despite adjustment for age, gender, delays in presentation, and use of more aggressive therapies, only CPD and the presence of shock or hemodynamic instability within 3 hours of presentation remained significant predictors of death. More aggressive therapy did not alter outcome.
Given the substantial cost and potential morbidity, aggressive therapy with thrombolysis or pulmonary embolectomy should be reserved for MPE patients. Further study into the interaction between embolus size and underlying cardiopulmonary function is needed to define the subset of HS-PE patients at highest risk and likely to benefit from more aggressive treatments.
A.M. Joffe, None.