Mortality of High-Risk PE Is, Well…High

Written by Samuel Rouleau

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A prospective study by the PERT Consortium found an in-hospital mortality rate of 20% in patients with high-risk PE. 41.9% of patients with high-risk PE were treated with advanced therapies (systemic thrombolytics, catheter-directed thrombolysis or embolectomy, surgical embolectomy, ECMO).

Your patient with a high-risk PE is sick – know the risks and treat aggressively
Some data suggest mortality of high-risk PE has increased in the United States.^1,2 Patients with high-risk pulmonary embolism (PE) are defined by sustained hypotension (SBP <90mmHg) or hemodynamic collapse.³ This multicenter, prospective study included 5,790 patients with acute PE. 1,442 patients with high-risk PE were compared to 2,976 classified as intermediate-risk PE (normotensive with evidence of right ventricular strain on imaging and/or elevated cardiac troponin levels).  Within the high-risk group, the authors also compared a subgroup of patients with catastrophic PE (cardiac arrest or high-dose vasopressors) to patients with non-catastrophic PE.

The unadjusted, in-hospital mortality rates for patients with high-risk and intermediate-risk PE were 20.6% and 3.7%, respectively. Malignancy and hypoxemia at presentation were associated with mortality on multivariate regression. Within the high-risk PE subgroup, the unadjusted mortality rates for catastrophic PE and non-catastrophic PE were 42.1% and 17.2%, respectively. Advanced therapies were used in 45.9% of high-risk PE patients. Patients with catastrophic PE were more likely to receive ECMO and systemic thrombolysis, and less likely to receive catheter-based interventions.

There is some study bias, in that PERT Consortium sites have 24/7 access to multidisciplinary teams and the entire spectrum of advanced therapies. Many hospitals do not have these resources, and many patients with high-risk PE do not receive systemic thrombolysis when indicated.⁴

How will this change my practice?
This study has several takeaways:

• PE that cause hypotension (high-risk PE) are deadly, though less than half of these patients receive advanced therapies. This is alarming.
• When treating a patient with high-risk PE, my first question is: “Are there contraindications to thrombolysis?” If no, give systemic thrombolytics, which is in accordance with AHA and ESC guidelines.
• If there is a contraindication, rapidly consult your specialists for consideration of catheter-directed therapies, surgical embolectomy, or ECMO. Transfer the patient if your shop does not offer advanced therapies.

Edited by Bo Stubblefield

Source
Contemporary Management and Outcomes of Patients With High-Risk Pulmonary Embolism. J Am Coll Cardiol. 2024;83(1):35-43. doi:10.1016/j.jacc.2023.10.026

Works Cited

1. Zuin M, Bikdeli B, Davies J, et al. Contemporary trends in mortality related to high-risk pulmonary embolism in US from 1999 to 2019. Thrombosis research. 2023;228:72-80.
2. Casey SD, Stubblefield WB, Luijten D, et al. Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2023.
3. Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). European heart journal. 2020;41(4):543-603.
4. Zuin M, Rigatelli G, Zuliani G, Zonzin P, Ramesh D, Roncon L. Thrombolysis in hemodynamically unstable patients: still underused: a review based on multicenter prospective registries on acute pulmonary embolism. Journal of thrombosis and thrombolysis. 2019;48(2):323-330.