Eric Secemsky1, Yuchiao Chang2, C Charles Jain3, Joshua A Beckman4, Jay Giri5, Michael R Jaff6, Kenneth Rosenfield7, Rachel Rosovsky8, Christopher Kabrhel9, Ido Weinberg10. 1. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston; Harvard Medical School, Boston; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston. 2. Harvard Medical School, Boston; Department of Medicine, Massachusetts General Hospital, Boston, Mass. 3. Cardiovascular Division, Department of Medicine, Mayo Clinic, Rochester, Minn. 4. Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn. 5. Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia. 6. Harvard Medical School, Boston; Newton-Wellesley Hospital, Boston. 7. Harvard Medical School, Boston; Division of Cardiology, The Fireman Vascular Center, Department of Medicine. 8. Hematology and Oncology Division. 9. Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston. 10. Harvard Medical School, Boston; Division of Cardiology, The Fireman Vascular Center, Department of Medicine. Electronic address: iweinberg@mgh.harvard.edu.
Abstract
BACKGROUND: Few contemporary studies have assessed the management and outcomes of patients with massive and submassive pulmonary embolism. Given advances in therapy, we report contemporary practice patterns and event rates among these patients. METHODS: We analyzed a prospective database of patients with massive and submassive pulmonary embolism. We report clinical characteristics, therapies, and outcomes stratified by pulmonary embolism type. Treatment escalation beyond systemic anticoagulation was defined as advanced therapy. Cox proportional hazards regression was used to identify predictors of 90-day mortality. RESULTS: Among 338 patients, 46 (13.6%) presented with massive and 292 (86.4%) with submassive pulmonary embolism. The average age was 63 ± 15 years, 49.9% were female, 32.0% had malignancy, and 21.9% had recent surgery. Massive pulmonary embolism patients received advanced therapy in 71.7% (30.4% systemic thrombolysis, 17.4% catheter-directed thrombolysis, 15.2% surgical embolectomy) and had greater 90-day mortality rates compared with submassive pulmonary embolism patients (41.3% vs 12.3%, respectively; P < .01). Most massive pulmonary embolism deaths (78.9%) occurred in-hospital, whereas mortality risk persisted after discharge for submassive pulmonary embolism. After multivariable adjustment, massive pulmonary embolism was associated with a 5.23-fold greater hazard of mortality (95% confidence interval, 2.70-10.13; P < .01). Advanced therapies among all pulmonary embolism patients were associated with a 61% reduction in mortality (95% confidence interval, 0.20-0.76; P < .01). CONCLUSIONS: Among contemporary massive and submassive pulmonary embolism patients, mortality remains substantial. Advanced therapies were frequently utilized and independently associated with lower mortality. Further investigation is needed to determine how to improve outcomes among these high-risk patients, including the optimal use of advanced therapies.
BACKGROUND: Few contemporary studies have assessed the management and outcomes of patients with massive and submassive pulmonary embolism. Given advances in therapy, we report contemporary practice patterns and event rates among these patients. METHODS: We analyzed a prospective database of patients with massive and submassive pulmonary embolism. We report clinical characteristics, therapies, and outcomes stratified by pulmonary embolism type. Treatment escalation beyond systemic anticoagulation was defined as advanced therapy. Cox proportional hazards regression was used to identify predictors of 90-day mortality. RESULTS: Among 338 patients, 46 (13.6%) presented with massive and 292 (86.4%) with submassive pulmonary embolism. The average age was 63 ± 15 years, 49.9% were female, 32.0% had malignancy, and 21.9% had recent surgery. Massive pulmonary embolismpatients received advanced therapy in 71.7% (30.4% systemic thrombolysis, 17.4% catheter-directed thrombolysis, 15.2% surgical embolectomy) and had greater 90-day mortality rates compared with submassive pulmonary embolismpatients (41.3% vs 12.3%, respectively; P < .01). Most massive pulmonary embolism deaths (78.9%) occurred in-hospital, whereas mortality risk persisted after discharge for submassive pulmonary embolism. After multivariable adjustment, massive pulmonary embolism was associated with a 5.23-fold greater hazard of mortality (95% confidence interval, 2.70-10.13; P < .01). Advanced therapies among all pulmonary embolismpatients were associated with a 61% reduction in mortality (95% confidence interval, 0.20-0.76; P < .01). CONCLUSIONS: Among contemporary massive and submassive pulmonary embolismpatients, mortality remains substantial. Advanced therapies were frequently utilized and independently associated with lower mortality. Further investigation is needed to determine how to improve outcomes among these high-risk patients, including the optimal use of advanced therapies.
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