Andrzej Łabyk, Michał Ciurzyński, Krzysztof Jankowski, Maciej Kostrubiec, Barbara Lichodziejewska, Piotr Bienias, Justyna Pedowska-Włoszek, Szymon Pacho, Piotr Palczewski, Piotr Pruszczyk

Background and aim: Despite significant progress on the diagnosis work-up of patients with suspented acute pulmonary embolism (APE), several therapeutic and prognostic issues have not yet been well established. Methods: We analysed the clinical course of 353 consecutive patients (141 males, 212 females, mean age 64.7 ± 18.12 years) with APE confirmed by contrast-enhanced multidetector computed tomography who were diagnosed and treated in a reference hospital between 2007 and 2009. Results: Among patients with APE, groups with high (HR), intermediate (IR) and low (LR) risk of early mortality were defined according to the recent European Society of Cardiology guidelines. High, intermediate and low risk groups included 23 patients (10 M, 13 F, age 70.13 ± 16.95 years), 146 patients (61 M, 85 F, age 65.77 ± 17.74 years), and 184 patients (70 M, 114 F, age 63.17 ± 18.45 years), respectively. Majority of patients (91.8%) were anticoagulated only with unfractionated or low-molecular-weight heparin, and thrombolysis was used in 24 patients, including 39.1% of HR patients, 8.9% of IR patients, and 1% of LR patients. In-hospital mortality rate was 7% overall (including 5.4% APE-related), 65.2% in HR (43.5% APE-related), 6.2% in IR (4.1% APE-related) and 2.2% in LR (1.63% APE-related). However, 4 of 9 high risk patients treated with thrombolysis died (mortality rate 44.4%), while mortality among HR patients not treated with thrombolysis reached 73.3%. Potential contraindications were taken into account before the decision to initiate thrombolysis. End-stage neoplasm or recent major surgery were considered contraindications for thrombolysis. Strong prognostic factors of overall in-hospital mortality included age (odd ratio [OR] 1.07, 95% confidence interval [CI] 1.02-1.12), heart rate (OR 1.04, 95% CI 1.02-1.06), and plasma creatinine level (OR 3.65, 95% CI 1.62-8.27), the latter also being a significant prognostic factor of mortality in low risk group (OR 3.9, 95% CI 1.6-9.8). NT-proBNP and troponin I plasma levels were also significant prognostic factors of in-hospital mortality (NT-proBNP: OR 5.91, 95% CI 2.38-14.65, p < 0.05; troponin I (cut-off value ≥ 0.1 μg/L): OR 2.77, 95% CI 0.97-7.93, p = 0.056). In the overall study population and also in non-high risk group, significant predictors of a combined endpoint (death, shock, intubation, catecholamines, and thrombolysis) were: age, heart rate, creatinine, troponin I, NT-proBNP, and tricuspid pressure gradient. Conclusions: Despite adequate treatment there is a possibility of haemodynamic collapse and the need for thrombolysis in approximately 9% of intermediate risk APE patients. Not only age and compromised haemodynamic status but also plasma creatinine, NT-proBNP, and troponin I levels are prognostic factors of early in-hospital mortality in patients with APE. Due to high mortality rate among non-thrombolysed high risk patients, their therapy should be more aggressive and contraindications for thrombolysis should be less restrictive.