Elsevier

Thrombosis Research

Volume 103, Issue 6, 15 September 2001, Pages V239-V244
Thrombosis Research

VESSELS ARTICLE
Risk Factors for Adverse Short-Term Outcome in Patients with Pulmonary Embolism

https://doi.org/10.1016/S0049-3848(01)00291-2Get rights and content

Abstract

Pulmonary embolism (PE) is a common and potentially fatal disease. Death usually occurs before hospital admission or in the initial in-hospital phase. A number of clinical and instrumental findings have been associated with a high risk of adverse short-term clinical outcomes in patients with PE. Advanced age, concomitant cardiopulmonary disease, and haemodynamic instability, as well as large perfusion defects at lung scanning and acute right heart dysfunction as assessed by echocardiography, are associated with adverse in-hospital outcome. Elevated serum levels of troponin I have been recently demonstrated to be associated with severe right ventricular dysfunction and adverse in-hospital outcome in patients with PE. Early recurrence of PE is associated with a high mortality rate. Right heart dysfunction, as assessed by echocardiography and an acute fall in platelet count, have been suggested as risk factors for recurrence of PE. A reduction in mortality in the subgroup of patients with a poor prognosis might be achieved by using more aggressive treatments such as thrombolysis and surgical or interventional procedures. However, such treatments are invariably associated with bleeding and other procedural complications.

Section snippets

Clinical Outcome in Patients With Pulmonary Embolism

The clinical outcome of patients with acute PE has been assessed in a number of studies, including three large registries. Three major adverse events have been observed in the short- (in-hospital) and long-term (3 months) follow-up: death, recurrence of PE, and bleeding (Table 1) [4].

In-hospital and 30-day clinical outcomes of patients with PE were assessed in Management and Prognosis in Pulmonary Embolism Trial (MAPPET) [5]. During the hospital stay, 69 of 719 (9.6%) patients with PE died,

Clinical Risk Factors Associated With Early Mortality

The role of specific clinical features at hospital admission in predicting the short-term outcome was assessed in MAPPET. At 30 days, death occurred in 14.4% and 7.3% of patients presenting with or without syncope, respectively (P=.012); in 12.6% and 7.3% of patients with or without hypotension, respectively (P=.021); and in 11.1% and 6.3% of patients with or without tachycardia, respectively (P=.06). However, neither syncope (OR=1.61; 95% confidence interval 0.9–2.80), hypotension (OR=1.44;

Size of Emboli and Clinical Outcome

The size of emboli, assessed by the size of the perfusion defects at diagnostic imaging, was assumed to be an objective measure of the severity of PE. The Miller index was introduced to standardize the quantification of angiographic vascular obstruction. This index, varying from 0 to 34, is obtained by the sum of the segmental branches of pulmonary arteries excluded from blood flow because of the presence of emboli.

Alpert [9] correlated the extent of angiographic perfusion defect (below or

Right Ventricular Dysfunction and Clinical Outcome

The prognostic value of right heart impairment due to PE has been demonstrated by the postmortem evidence of right ventricular infarction in the absence of right ventricular wall hypertrophy in patients who died with acute PE [11].

Electrocardiographic signs of right ventricular strain (S1Q3T3 complex, right bundle block, pulmonary P waves, T waves inversion in right precordial leads, etc.) were correlated with the extent of the perfusion defect as assessed by lung scan and pulmonary

Echocardiography and Clinical Outcome

Recent studies have demonstrated the feasibility and utility of transthoracic echocardiography in assessing right ventricular overload. Mc Connell et al. [16] showed that hypokinesis of the midapical, right ventricular free wall is a sign of acute right ventricular overload and correlated with acute PE. Increased right ventricular diameter, left/right ventricular diameter ratio, and right ventricular dysfunction (hypokinesis) are all signs of right side overload. None of these criteria may

Determinants of Recurrence of Pulmonary Embolism

Recurrence of PE is a common event. Sixteen percent of MAPPET patients experienced a recurrence within 30 days of the index event. Short-term recurrence of PE is associated with high mortality. In ICOPER, 7.9% of patients experienced recurrent PE within the 3-month follow-up period; in these patients, a 33.7% and a 46.8% mortality was observed before discharge and at 90-day follow-up, respectively [4]. Mortality rate was 8.5% and 13.4%, respectively, in patients without recurrence. Recurrent PE

Conclusions

The rate of adverse outcome in patients with PE remains high. Despite a wide spectrum of severity at presentation the large majority of patients with PE receive similar antithrombotic treatment. Further studies should be performed to define risk factors for adverse clinical outcome in order to establish a prognostic categorization of patients with PE. Echocardiography appears promising in predicting in-hospital recurrence and death. Interventional studies and assessing the clinical benefit of

References (25)

  • MT Morrell et al.

    The post-mortem incidence of pulmonary embolism in a hospital population

    Br J Surg

    (1968)
  • Goldhaber SZ, Visani L, De Rosa M for ICOPER. Acute pulmonary embolism: clinical outcomes in the International...
  • Cited by (0)

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