Impact of the Concurrent Acute Illness on the Short-Term Prognosis in Patients with Hemodynamically Stable Acute Pulmonary Embolism.

Online January 17, 2023 doi: 10.3400/avd.oa.22-00007 Ann Vasc Dis Vol. 16, No. 1; 2023; pp 24–30 Original Article Impact of the Concurrent Acute Illness on the Short-Term Prognosis in Patients with Hemodynamically Stable Acute Pulmonary Embolism Hironori Kobayashi, MD, Kitae Kim, MD, PhD, and Yutaka Furukawa, MD, PhD Objective: Acute pulmonary embolism (PE) is potentially fatal. Age, sex, chronic comorbidities, vital signs, and echocardiographic findings are well-known predictive indicators of the short-term mortality. However, the impact of concurrent acute illness on the prognosis is unclear. Materials and Methods: This is a retrospective cohort study using data of hospitalized patients with a diagnosis of acute PE without hemodynamic instability. The outcome measure was 30-day all-cause mortality after diagnosis of acute PE. Results: A total of 130 patients were analyzed (68.5±15.5 years old, 62.3% female). Eight patients (6.2%) had concurrent acute illness. The proportion of the simplified pulmonary embolism severity index (sPESI)≥1, and positive findings of right ventricular overload were similar between the two groups. Six patients (4.9%) without concurrent acute illness died; whereas, three patients (37.5%) with concurrent acute illness died (p=0.011). Concurrent acute illness was associated with 30-day all-cause mortality in the univariate logistic model (odds ratio: 11.6, 95% confidence interval; 2.2–60.4; p=0.008). Conclusion: In patients with hemodynamically stable acute PE, short-term prognosis was significantly worse in patients with concurrent acute illness than those without concurrent acute illness. Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan Received: January 13, 2022; Accepted: November 6, 2022 Corresponding author: Kitae Kim, MD, PhD. Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan Tel: +81-78-302-4321, Fax: +81-78-302-7537 E-mail: ©2023 The Editorial Committee of Annals of Vascular Diseases. This article is distributed under the terms of the Creative Commons Attribution License, which permits use, distribution, and reproduction in any medium, provided the credit of the original work, a link to the license, and indication of any change are properly given, and the original work is not used for commercial purposes. Remixed or transformed contributions must be distributed under the same license as the original. 24 Keywords: pulmonary embolism, acute illness, short-term prognosis Introduction Acute pulmonary embolism (PE) is a common and potentially fatal illness, and the annual incidence was reported to be rapidly growing from 28 to 126 per 1,000,000 people between 1996 and 2011.1,2) Acute PE has a broad range of the short-term mortality, ranging from 1%3–7) to over 50%.8,9) The immediate risk stratification is essential to provide an appropriate initial treatment because the majority of death occurs in the first 48 h in patients with acute PE.9,10) After identifying hemodynamically unstable patients who require immediate referral for reperfusion treatment, the risk-adjusted management strategy on a basis of the simplified pulmonary embolism severity index (sPESI) and right ventricular overload on echocardiography is recommended in the current guideline.11) The sPESI is well-validated clinical prognostic scoring system consisting of age, chronic comorbidities, and vital signs, which helps to identify the low-risk patients.3–7) Right ventricular dysfunction detected by transthoracic echocardiography was also reported to be effective to assess the early risk of patients with acute PE.11,12) Right ventricle/left ventricle (RV/LV) diameter ratio of ≥1.0 and tricuspid annular plane systolic excursion (TAPSE) <16 mm have most frequently been reported to be associated with unfavorable prognosis among echocardiographic parameters.11,13–16) Hospitalized patients with acute illness such as acute respiratory failure and infectious disease, including critically ill patients, are at high risk of venous thromboembolism (VTE),17,18) and in-hospital-onset VTE is associated with poor prognosis.19) On the other hand, acute PE can be complicated by concurrent acute illness other than deep vein thrombosis. Concurrent acute illness may affect the clinical course and prognosis; however, the impact of concurrent acute illness on the short-term prognosis is Annals of Vascular Diseases Vol. 16, No. 1 (2023) Concurrent Acute Illness in Acute PE not well investigated and is not considered in the risk assessment of acute PE in the current guideline.11) Thus, the present study aimed to investigate whether the concurrent acute illness affects the short-term prognosis as well as the sPESI and RV dysfunction detected by echocardiography in patients with hemodynamically stable acute PE. Materials and Methods Study design and patient population This is a single center retrospective cohort study enrolling patients admitted to Kobe City Medical Center General Hospital with a diagnosis of acute PE by way of the emergency department (ED) between January 1, 2010 and February 25, 2020. The Institutional Review Board of Kobe City Medical Center General Hospital approved the study (No. zn201209). The consent for the participation of this study was obtained through an opt-out methodology, and written informed consent from each patient was waived. Eligibility for this study required that patients have acute PE confirmed by objective imaging testing (computed tomography pulmonary angiography, high-probability ventilation/perfusion (V/Q) scan, or pulmonary angiography). The exclusion criteria are PE with hemodynamic instability at the ED before admission, no use of anticoagulation or fibrinolytic agents within 24 h of diagnosis, unavailability of data about the sPESI or right ventricular overload on transthoracic echocardiography, and loss to follow-up within 30 days of hospitalization. PE with hemodynamic instability was defined as PE with one or more of the following clinical presentations: cardiac arrest, obstructive shock (systolic blood pressure (BP) <90 mmHg or vasopressors required to achieve a BP ≥90 mmHg despite an adequate filling status, in combination with end-organ hypoperfusion), or persistent hypotension (systolic BP <90 mmHg or a systolic BP drop ≥40 mmHg for >15 min, not caused by new-onset arrhythmia, hypovolemia, or sepsis).11) Data collection and outcome measures Data for patient characteristics and follow-up information were collected from hospital charts. The baseline variables analyzed were concurrent acute illness, age, sex, underlying diseases of malignancy, heart failure, chronic lung disease, vital signs at the ED, imaging modality for the definitive diagnosis, sPESI, right ventricular overload on transthoracic echocardiography, concurrent proximal deep vein thrombosis, initial treatment of anticoagulation a (...truncated)