Risk assessment and management strategies in older patients with acute pulmonary embolism

Abstract

Background: Managing older patients with acute pulmonary embolism (PE) is challenging due to their underrepresentation in clinical trials, comorbidities, and increased complication risk.

Objectives: To evaluate risk assessment and management outcomes in older patients with PE focusing on home and reperfusion treatment.

Methods: A retrospective analysis was conducted on patients aged 70 years or older diagnosed with acute PE at an academic medical center (2015-2022).

Results: In total, 242 patients with a mean age of 77 years were included. All 59 patients with negative Hestia criteria were discharged ≤24 hours, and in total, 81 patients (35%) received home treatment. Among these 14-day mortality and recurrent venous thromboembolism were 0% and major bleeding occurred in 1.3% (1 patient, 95% CI: 0.11-6.1). European Society of Cardiology risk classification showed 9 low-risk (3.9%), 199 intermediate-risk (87%), and 20 high-risk (8.8) patients with PE. In 5 of the 20 high-risk patients, hypotension was mainly caused by another condition, that is, sepsis. Eight high-risk patients received reperfusion therapy. The 14-day mortality rate was 51% in high-risk patients (95% CI: 27-71); 5 of 8 patients receiving reperfusion treatment died within 5 days. Patients with an Acute Presenting Older Patient score of ≥45% had higher 14-day mortality (28%; 95% CI: 12-46) compared with <45% (3.2%; 95% CI: 0.85-8.3; hazard ratios: 10.2; 95% CI: 2.6-39).

Conclusion: Selecting for home treatment using Hestia criteria was safe for older patients with PE in our cohort. Mortality in the high-risk group was high also when receiving reperfusion treatment. The European Society of Cardiology risk classification and Acute Presenting Older Patient score identified patients at higher mortality risk, suggesting their potential utility in clinical decision-making.

Keywords: Emergency Medical Services; clinical decision-making; frail elderly; geriatrics; pulmonary embolism.