Predictors of 6 month-mortality following intermediate-high and high risk pulmonary embolism
Authors: Martin Cabeza M M , Igareta Herraiz A T , Poveda Pinedo I D , Lemus Martin A , Sansegundo Burgueno F , Munoz Rodriguez R , Castro Martin J J , Rivero Garcia M A , Dorta Olivero A , Comas Romero P , Garcia Gonzalez M J , Jorge Perez P 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

BACKGROUND
Pulmonary embolism (PE) is the third most frequent cardiovascular disease and is associated with high mortality, during the admission and short-term follow-up. Due to Right Ventricular (RV) dysfunction or Pulmonary Hypertension (PH), also because anticoagulation's bleeding complications and PE may be the first manifestation of underlying cancer.

Purpose
To determine clinical and echocardiography characteristics and 6 month-mortality of patients with an intermediate-high or high PE admitted in the Acute Cardiovascular Care Unit (ACCU).

Methods
The present study is a retrospective analysis of 137 patients with intermediate-high and high risk PE admitted in our ACCU between May-2017 and May-2021. Clinical, biochemical and echocardiographic variables were analyzed on admission, prior to discharge and 6 month follow-up period. Mortality was evaluated at 6 months. Univariate logistic analysis was used to analyze markers associated with mortality.

Results
The majority were women 77 (56%), aged between 16-90 years. 78 (57%) had hypertension, 64(46%) Dyslipemia, 50(37%) obesity and 12 (9%) had previous cancer. On admission 76( 56%) patients consulted for dyspnea and 52(38%) for syncope. 81 (60%) presented respiratory failure (pO2&lt;60 mmHg), 98(72%) had elevated Nt-proBNP (3583 ±4874) and 109 (80%) Troponin. 36 (27%) presented a Shock Index&gt;1. On admission echocardiography, 90 (66%) had RV dysfunction (TAPSE≤16mm), 120(89%) a dilated RV (basal RV/LV ratio&gt;1.0) and PH was: 44 (36%) Mild, 48 (39%) Moderate and 22 (18%) Severe.
Regarding first PE treatment patients received: 85 (62%) Heparin Sodium, 11 (8%) Systemic fibrinolysis, 31 (23%) Catheter-directed therapies and 10 (7%) LMWH. During the admission 6 (5%) patients suffer minor and 9 (7%) major bleeding. At discharge 101 (82%) improved RV function and 95 (82%) improved PH (None 62 (54 %), Mild 40 (35%), Moderate 11 (9%) and Severe 2 (2%)).
In 6 months follow-up, 13(10%) died, 3(2%) were readmitted because of new PE and 4(3%) because of major bleeding. New cancer was diagnosed in 12(9%) patients. The majority (74%) were in NYHA-I.
The risk of death at 6 months (Table 1) were significantly increased in diabetes patients (46% vs 16%,p=0.009), those in which RV dysfunction persisted (50% vs 8%,p=0.001), in case of major bleeding readmission (43% vs 0.8%,p=0.001) or those with an underlying cancer (57% vs 7%,p=0.001).
Variables associated with 6 months-mortality in the univariate analysis (Table 2) are: Nt-proBNP, Major bleeding during admission and readmission, an underlying cancer, and RV dysfunction prior to discharge, a persisted Dilated-RV and moderate or severe PH before discharge.

Conclusion
In our sample, in patients admitted due to intermediate-high or high risk PH, the persistence of RV dysfunction, having diabetes and suffering from cancer or major bleeding in a short follow-up increases the risk of death. Although our data may be misestimated because of the low rate of events.