Impact of thyroid dysfunction on short-term outcomes and long-term mortality in patients with pulmonary embolism.

BACKGROUND: A large body of evidence suggest an impact of thyroid function on outcomes of cardiovascular diseases, but results for acute pulmonary embolism (PE) are sparse. METHODS: We analysed the impact of hypothyroidism as well as hyperthyroidism on the short and long-term outcomes of patients with acute PE. The impact was compared to the group of euthyroid PE patients as reference group. RESULTS: Overall, 831 PE patients (median age 69 [IQR 56-77] years; 52.2% females) were analysed. Among these, 734 patients (88.3%) were classified as euthyroid, 40 (4.8%) as hypothyroid and 57 (6.9%) as hyperthyroid. PE patients with hypothyroidism had higher rates of adverse in-hospital outcomes (37.5% vs. 11.6%, P < 0.001), PE-related (22.5% vs. 4.8%, P < 0.001) and all-cause in-hospital death (25.0% vs. 6.8%, P < 0.001), whereas hyperthyroidism did not affect in-hospital outcomes. Long-term mortality was higher in hypothyroidism (52.5% vs. 28.9%, P = 0.002) and hyperthyroidism (43.9% vs. 28.9%, P = 0.018) compared to euthyroid function. In the 750 normotensive PE patients, hyperthyroidism affected adverse in-hospital outcome (OR 2.58 [95%CI 1.12-5.97], P = 0.026) and PE-related in-hospital mortality (OR 3.50 [95%CI 1.10-11.17], P = 0.035) in comparison to euthyroid PE patients, while hypothyroidism showed no influence. Elevated fT4 (HR 1.75 [95%CI 1.16-2.63], P = 0.007) and reduced fT3 values (HR 2.51 [95%CI 1.48-4.28], P = 0.001) were associated with increased long-term mortality. CONCLUSION: Thyroid dysfunction had a substantial impact on short and long-term outcomes of patients with acute PE. Elevated fT4 and reduced fT3 values were significantly associated with increased long-term mortality in normotensive PE patients.

Prognostic value of right atrial dilation in patients with pulmonary embolism.

AIMS: Right atrial (RA) dilation and stretch provide prognostic information in patients with cardiovascular diseases. We investigated the prevalence, confounding factors and prognostic relevance of RA dilation in patients with pulmonary embolism (PE). METHODS: Overall, 609 PE patients were consecutively included in a prospective single-centre registry between September 2008 and August 2017. Volumetric measurements of heart chambers were performed on routine non-electrocardiographic-gated computed tomography and plasma concentrations of mid-regional pro-atrial natriuretic peptide (MR-proANP) measured on admission. An in-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration. RESULTS: Patients with an adverse outcome (11.2%) had larger RA volumes (median 120 (interquartile range 84-152) versus 102 (78-134) mL; p=0.013), RA/left atrial (LA) volume ratios (1.7 (1.2-2.4) versus 1.3 (1.1-1.7); p<0.001) and MR-proANP levels (282 (157-481) versus 129 (64-238) pmol·L-1; p<0.001) compared to patients with a favourable outcome. Overall, 499 patients (81.9%) had a RA/LA volume ratio ≥1.0 and a calculated cut-off value of 1.8 (area under the curve 0.64, 95% CI 0.56-0.71) predicted an adverse outcome, both in unselected (OR 3.1, 95% CI 1.9-5.2) and normotensive patients (OR 2.7, 95% CI 1.3-5.6). MR-proANP ≥120 pmol·L-1 was identified as an independent predictor of an adverse outcome, both in unselected (OR 4.6, 95% CI 2.3-9.3) and normotensive patients (OR 5.1, 95% CI 1.5-17.6). CONCLUSIONS: RA dilation is a frequent finding in patients with PE. However, the prognostic performance of RA dilation appears inferior compared to established risk stratification markers. MR-proANP predicted an in-hospital adverse outcome, both in unselected and normotensive PE patients, integrating different prognostic relevant information from comorbidities.

Temporal trends in management and outcome of pulmonary embolism: a single-centre experience.

BACKGROUND: Real-world data on the impact of advances in risk-adjusted management on the outcome of patients with pulmonary embolism (PE) are limited. METHODS: To investigate temporal trends in treatment, in-hospital adverse outcomes and 1-year mortality, we analysed data from 605 patients [median age, 70 years (IQR 56-77) years, 53% female] consecutively enrolled in a single-centre registry between 09/2008 and 08/2016. RESULTS: Over the 8-year period, more patients were classified to lower risk classes according to the European Society of Cardiology (ESC) 2014 guideline algorithm while the number of high-risk patients with out-of-hospital cardiac arrest (OHCA) increased. Although patients with OHCA had an exceptionally high in-hospital mortality rate of 59.3%, the rate of PE-related in-hospital adverse outcomes (12.2%) in the overall patient cohort remained stable over time. The rate of reperfusion treatment was 9.6% and tended to increase in high-risk patients. We observed a decrease in the median duration of in-hospital stay from 10 (IQR 6-14) to 7 (IQR 4-15) days, an increase of patients discharged early from 2.1 to 12.2% and an increase in the use of non-vitamin K-dependent oral anticoagulants (NOACs) from 12.6 to 57.2% in the last 2 years (09/2014-08/2016) compared to first 6 years (09/2008-08/2014). The 1-year mortality rate (16.9%) remained stable throughout the study period. CONCLUSION: In-hospital adverse outcomes and 1-year mortality remained stable despite more patients with OHCA, shorter in-hospital stays, more patients discharged early and a more frequent NOAC use.

Prediction and prognostic importance of in-hospital major bleeding in a real-world cohort of patients with pulmonary embolism.

BACKGROUND: Assessment of bleeding risk in patients with pulmonary embolism (PE) is challenging. Recently, the VTE-BLEED score was shown to predict major bleeding. Therefore, we aimed to investigate the VTE-BLEED score and assess the prognostic impact of major bleeding in a real-world cohort of PE patients. METHODS: Consecutive PE patients included in a prospective single-center cohort study between 09/2008 and 11/2016 were eligible for analysis; patients treated with thrombolysis were excluded. The VTE-BLEED was calculated post-hoc; in-hospital major bleeding was defined using the ISTH definition. RESULTS: Overall, 522 patients (median age 69, IQR 56-78 years; 53% female) were included in the present analysis; major bleeding occurred in 18 (3.5%) patients. A VTE-BLEED score ≥2 points identified patients at high-risk for major bleeding (OR 3.7, 95% CI 1.1-13.0, sensitivity 83%, specificity 42%). Additionally, a GFR <30 ml/min/1.73 m2 (OR 6.0, 95% CI 1.8-19.8) and previous surgery (OR 3.6, 95% CI 1.4-9.3) were associated with major bleeding. A less frequent use of unfractionated heparin as initial treatment was associated with a decrease of major bleeding over time. Major bleeding was identified as strong predictor of in-hospital (OR 7.7, 95% CI 2.3-25.8) and 1-year mortality (HR 3.6, 95% CI 2.0-6.6), especially in normotensive patients (OR 12.1, 95% CI 3.5-43.0 and HR 6.0, 95% CI 2.9-12.6, respectively). CONCLUSIONS: In a real-world cohort, the VTE-BLEED score identified PE patients at risk for in-hospital major bleeding. However, for assessment of bleeding risk, renal function and previous surgery should be considered. Major bleeding emerged as strong predictor of in-hospital and 1-year mortality.