Matthias Ebner1,2, Carmen Sentler3, Veli-Pekka Harjola4, Héctor Bueno5,6,7, Markus H Lerchbaumer8, Gerd Hasenfuß3,9, Kai-Uwe Eckardt10, Stavros V Konstantinides11,12, Mareike Lankeit2,3,11,13. 1. Department of Cardiology and Angiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany. 2. German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Germany. 3. Clinic of Cardiology and Pneumology, University Medical Center, Göttingen, Germany. 4. Department of Emergency Medicine and Services, University of Helsinki, Emergency Medicine, Helsinki University Hospital, Helsinki, Finland. 5. Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain. 6. Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital, 12 de Octubre (imas12), Madrid, Spain. 7. Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain. 8. Department of Radiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany. 9. German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Germany. 10. Department of Nephrology and Medical Intensive Care, Charité - University Medicine Berlin, Germany. 11. Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany. 12. Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece. 13. Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
Abstract
AIMS: The 2019 European Society of Cardiology (ESC) guidelines provide a revised definition of high-risk pulmonary embolism (PE) encompassing three clinical presentations: Cardiac arrest, obstructive shock, and persistent hypotension. This study investigated the prognostic implications of this new definition. METHODS AND RESULTS: Data from 784 consecutive PE patients prospectively enrolled in a single-centre registry were analysed. Study outcomes include an in-hospital adverse outcome (PE-related death or cardiopulmonary resuscitation) and in-hospital all-cause mortality. Overall, 86 patients (11.0%) presented with high-risk PE and more often had an adverse outcome (43.0%) compared to intermediate-high-risk patients (6.1%; P < 0.001). Patients with cardiac arrest had the highest rate of an in-hospital adverse outcome (78.4%) and mortality (59.5%; both P < 0.001 compared to intermediate-high-risk patients). Obstructive shock and persistent hypotension had similar rates of adverse outcomes (15.8% and 18.2%, respectively; P = 0.46), but the only obstructive shock was associated with an increased all-cause mortality risk. Use of an optimised venous lactate cut-off value (3.8 mmol/L) to diagnose obstructive shock allowed differentiation of adverse outcome risk between patients with shock (21.4%) and persistent hypotension (9.5%), resulting in a net reclassification improvement (0.24 ± 0.08; P = 0.002). CONCLUSION: The revised ESC 2019 guidelines definition of high-risk PE stratifies subgroups at different risk of in-hospital adverse outcomes and all-cause mortality. Risk prediction can be improved by using an optimised venous lactate cut-off value to diagnose obstructive shock, which might help to better assess the risk-to-benefit ratio of systemic thrombolysis in different subgroups of high-risk patients.
AIMS: The 2019 European Society of Cardiology (ESC) guidelines provide a revised definition of high-risk pulmonary embolism (PE) encompassing three clinical presentations: Cardiac arrest, obstructive shock, and persistent hypotension. This study investigated the prognostic implications of this new definition. METHODS AND RESULTS: Data from 784 consecutive PE patients prospectively enrolled in a single-centre registry were analysed. Study outcomes include an in-hospital adverse outcome (PE-related death or cardiopulmonary resuscitation) and in-hospital all-cause mortality. Overall, 86 patients (11.0%) presented with high-risk PE and more often had an adverse outcome (43.0%) compared to intermediate-high-risk patients (6.1%; P < 0.001). Patients with cardiac arrest had the highest rate of an in-hospital adverse outcome (78.4%) and mortality (59.5%; both P < 0.001 compared to intermediate-high-risk patients). Obstructive shock and persistent hypotension had similar rates of adverse outcomes (15.8% and 18.2%, respectively; P = 0.46), but the only obstructive shock was associated with an increased all-cause mortality risk. Use of an optimised venous lactate cut-off value (3.8 mmol/L) to diagnose obstructive shock allowed differentiation of adverse outcome risk between patients with shock (21.4%) and persistent hypotension (9.5%), resulting in a net reclassification improvement (0.24 ± 0.08; P = 0.002). CONCLUSION: The revised ESC 2019 guidelines definition of high-risk PE stratifies subgroups at different risk of in-hospital adverse outcomes and all-cause mortality. Risk prediction can be improved by using an optimised venous lactate cut-off value to diagnose obstructive shock, which might help to better assess the risk-to-benefit ratio of systemic thrombolysis in different subgroups of high-risk patients.