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