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

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: 3.276.38; P < 0.01), extracorporeal membrane oxygenation use (OR: 2.86; 95% CI: 1.12-7.30; P = 0.03), identified clot -intransit (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 inhospital 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. (J Am Coll Cardiol 2024;83:35-43) (c) 2024 by the American College of Cardiology Foundation.