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. 2024 Jan 2;83(1):35-43.
doi: 10.1016/j.jacc.2023.10.026.

Contemporary Management and Outcomes of Patients With High-Risk Pulmonary Embolism

Taisei Kobayashi  1 , Steven Pugliese  2 , Sanjum S Sethi  3 , Sahil A Parikh  3 , Joshua Goldberg  4 , Fahad Alkhafan  5 , Clara Vitarello  5 , Kenneth Rosenfield  6 , Robert Lookstein  7 , Brent Keeling  8 , Andrew Klein  9 , C Michael Gibson  10 , Lauren Glassmoyer  11 , Sameer Khandhar  11 , Eric Secemsky  12 , Jay Giri  13
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Free article

Contemporary Management and Outcomes of Patients With High-Risk Pulmonary Embolism

Taisei Kobayashi et al. J Am Coll Cardiol. .
Free article

Abstract

Background: Contemporary care patterns/outcomes in high-risk pulmonary embolism (PE) patients are unknown.

Objectives: This study sought to characterize the management of high-risk PE patients and identify factors associated with poor outcomes.

Methods: A retrospective analysis of the PERT (Pulmonary Embolism Response Team) Consortium Registry was performed. Patients presenting with intermediate-risk PE, high-risk PE, and catastrophic PE (those with hemodynamic collapse) were identified. Patient characteristics were compared with chi-square testing for categorical covariates and Student's t-test for continuous covariates. Multivariable logistic regression was used to assess associations between clinical characteristics and outcomes in the high-risk population.

Results: Of 5,790 registry patients, 2,976 presented with intermediate-risk PE and 1,442 with high-risk PE. High-risk PE patients were more frequently treated with advanced therapies than intermediate-risk PE patients (41.9% vs 30.2%; P < 0.001). In-hospital mortality (20.6% vs 3.7%; P < 0.001) and major bleeding (10.5% vs. 3.5%; P < 0.001) were more common in high-risk PE. Multivariable regression analysis demonstrated vasopressor use (OR: 4.56; 95% CI: 3.27-6.38; P < 0.01), extracorporeal membrane oxygenation use (OR: 2.86; 95% CI: 1.12-7.30; P = 0.03), identified clot-in-transit (OR: 2.26; 95% CI: 1.13-4.52; P = 0.02), and malignancy (OR: = 1.70; 95% CI: 1.13-2.56; P = 0.01) as factors associated with in-hospital mortality. Catastrophic PE patients (n = 197 [13.7% of high-risk PE patients]) had higher in-hospital mortality (42.1% vs 17.2%; P < 0.001) than those presenting with noncatastrophic high-risk PE. Extracorporeal membrane oxygenation (13.3% vs. 4.8% P < 0.001) and systemic thrombolysis (25% vs 11.3%; P < 0.001) were used more commonly in catastrophic PE.

Conclusions: In the largest analysis of high-risk PE patients to date, mortality rates were high with the worst outcomes among patients with hemodynamic collapse.

Keywords: ECMO; catheter-directed embolectomy; catheter-directed thrombolysis; high-risk pulmonary embolism; pulmonary embolism; systemic thrombolysis.

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Conflict of interest statement

Funding Support and Author Disclosures This work was funded through a grant from the PERT Consortium, a 501(c)3 not-for-profit organization. Dr Kobayashi’s institution has received funding for research from Inari medical and Endovascular Engineering. Dr Sethi has received honoraria/consulting fees from Boston Scientific, Janssen, Chiesi, Terumo, and Inari. Dr Parikh has received institutional research funding from Abbott, Boston Scientific, TriReme Medical, Shockwave Medical, Surmodics, Reflow Medical, Concept Medical, Veryan Medical, and MedAlliance; has served as an advisor to Abbott, Boston Scientific, Cordis, Medtronic, and Philips; and has served as a consultant for Terumo, Inari, Penumbra, and Canon. Dr Rosenfield has served as a consultant or on the scientific advisory board for Abbott Vascular, Althea Medical, Angiodynamics, Auxetics, Becton Dickinson, Boston Scientific, Contego, Crossliner, Imperative Care/Truvic, Innova Vascular, Inspire MD, Janssen/Johnson and Johnson, Magneto, Mayo Clinic, MedAlliance, Medtronic, Neptune Medical, Penumbra, Philips, Surmodics, Terumo, Thrombolex, Vasorum, Vantis Vascular, and Vumedi; owns equity or stock options in Access Vascular, Aerami, Althea Medical, Auxetics, Contego, Endospan, Imperative Care/Truvic, Innova Vascular, InspireMD, JanaCare, Magneto, MedAlliance, Neptune Medical, Orchestra, Prosomnus, Shockwave, Skydance, Summa Therapeutics, Thrombolex, Valcare, Vantis Vascular, Vasorum, and Vumedi; his institution has received funding from the National Institutes of Health, Abiomed, Boston Scientific, Novo Nordisk, Penumbra, Gettinge-Atrium; and has served on the Board of Directors of the National PERT Consortium. Dr Lookstein has served on the advisory board for Boston Scientific and Medtronic; has served as a consultant for Penumbra Vascular, Abbott Vascular, Neptune Medical, Imperative Vascular, Becton Dickinson Vascular, Biosense Webster, and Cordis Vascular; and owns equity in Imperative Vascular, Innova Vascular, Thrombolex, and Summa Vascular. Dr Gibson has served as a consultant for Alexion, AstraZeneca, Bayer, Janssen, and CytoSorbents. Dr Khandhar has received consulting fees from Inari Medical. Dr Secemsky has received consulting fees from Abbott, Bayer, BD, Boston Scientific, Cook, Cordis, CSI, HeartFlow, Inari, InfraRedx, Medtronic, Philips, RapidAI, Shockwave, and VentureMed; and his institution has received research funding from the National Institutes of Health/National Heart, Lung, and Blood Institute (K23HL150290), the U.S. Food and Drug Administration, the Society for Cardiovascular Angiography and Interventions, BD, Boston Scientific, Cook, CSI, Laminate Medical, Medtronic, and Philips. Dr Giri has served on the advisory board for and his institution has received research funding from Boston Scientific, Abbott Vascular, Recor Medical, Inari Medical, Edwards, and Abiomed; and owns equity in Endovascular Engineering. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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