Clinical Syndromes and Clinical Outcome in Patients With Pulmonary Embolism: Findings From the RIETE Registry

doi:10.1378/chest.130.6.1817

Chest

Volume 130, Issue 6, December 2006, Pages 1817-1822

https://doi.org/10.1378/chest.130.6.1817 Get rights and content

Introduction

The influence of the clinical syndromes of pulmonary embolism (PE) on clinical outcome has not been evaluated.

Patients and methods

The Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) is an ongoing registry of consecutive patients with acute venous thromboembolism. In this study, all enrolled patients with acute PE without preexisting cardiac or pulmonary disease were classified into three clinical syndromes: pulmonary infarction, isolated dyspnea, or circulatory collapse. Their clinical characteristics, laboratory findings, and 3-month outcomes were compared.

Results

As of January 2005, 4,145 patients with acute, symptomatic, objectively confirmed PE have been enrolled in RIETE. Of them, 3,391 patients (82%) had no chronic lung disease or heart failure: 1,709 patients (50%) had pulmonary infarction, 1,083 patients (32%) had isolated dyspnea, and 599 patients (18%) had circulatory collapse. Overall, 149 patients (4.4%) died during the first 15 days of therapy: 2.5% with pulmonary infarction, 6.2% with isolated dyspnea (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.7 to 3.8), and 6.5% with circulatory collapse (OR, 2.7; 95% CI, 1.7 to 4.2). From days 16 to 90, 31 patients had recurrent PE; 5 of 14 patients (36%) with pulmonary infarction died of their new PE, compared with 5 of 10 patients (50%) with isolated dyspnea, and all 7 patients (100%) with circulatory collapse.

Conclusions

PE patients with pulmonary infarction (50% of the whole series) had a significantly lower mortality rate both during initial therapy and after discharge.

Section snippets

Inclusion and Exclusion Criteria

Patients with symptomatic, acute DVT or PE confirmed by objective tests (ie, contrast venography, ultrasonography, or impedance plethysmography for suspected DVT; pulmonary angiography, lung scintigraphy, or helical CT scan for suspected PE) were consecutively enrolled in RIETE. Patients were excluded if they were participating in a therapeutic clinical trial or were unavailable for follow-up. All patients provided oral consent to their participation in the registry, in accordance with the

Results

As of January 2005, 4,145 patients with acute, symptomatic, objectively confirmed PE were enrolled in RIETE. Of them, 3,391 patients (82%) had no chronic lung disease or heart failure: 1,709 patients (50%) had pulmonary infarction, 1,083 patients (32%) had isolated dyspnea, and 599 patients (18%) had circulatory collapse. PE diagnosis was confirmed in 1,965 patients with positive CT scan results, 1,402 patients with high-probability V/Q lung scan results, 12 patients with visualization of a

Discussion

Our data, obtained from a large prospective series of consecutive patients with acute, symptomatic PE, confirm that their clinical presentation on hospital admission may have prognostic value. Indeed, the 6.2% and 6.5% mortality rates during the first 15 days of therapy in patients who presented with isolated dyspnea or circulatory collapse, respectively, clearly outweighed the 2.5% mortality rate in those with pulmonary infarction, who represented 50% of the whole series. These differences may

Members of the RIETE Group

Spain: Arcelus J.I.; Barba R.; Barrón M.; Beato J.L.; Blanco A.; Bugés J.; Cabezudo M.A.; Casado I.; Conget F.; De las Heras G.; Falgá C.; Fernández-Capitán C.; Gallego P.; García-Bargado F.; Grau E.; Guijarro R.; Guil M.; Gutiérrez J.; Hernández L.; Jiménez D.; Laserna E.; Lecumberri R.; Lobo J.L..; López F.; López L.; López I.; Maestre A.; Martín J.J.; Monreal M.; Montes J.; Naufall M.D.; Nieto J.A.; Núñez M.J.; Orue M.T.; Otero R.; Pedrajas J.M.; Portillo J.; Rabuñal R.; Raguer E.; Raventós

ACKNOWLEDGMENT

We express our gratitude to the Registry Coordinating Center, S & H Medical Science Service, for their logistic and administrative support.

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Cited by (69)

Pulmonary infarction in acute pulmonary embolism
2021, Thrombosis Research
Citation Excerpt :
Several studies assessed the mortality in PE patients with infarction. In pulmonary infarction as a clinical syndrome, a lower in-hospital mortality (0% in pulmonary infarction vs. 25% in circulatory collapse and 14% in isolated dyspnea) (67) and 15-day mortality (2.5% in pulmonary infarction vs. 6.2% in circulatory collapse and 6.7% in isolated dyspnea) (34) were shown as compared to other clinical PE syndromes. As the clinical syndrome is based on pleuritic chest pain and hemoptysis, it is thought that these patients present earlier to medical care, and reflect smaller, more peripheral emboli, explaining the lower mortality.
Pulmonary infarction results from occlusion of the distal pulmonary arteries leading to ischemia, hemorrhage and ultimately necrosis of the lung parenchyma. It is most commonly caused by acute pulmonary embolism (PE), with a reported incidence of around 30%. Following an occlusion of the pulmonary artery, the bronchial arteries are recruited as primary source of perfusion of the pulmonary capillaries. The relatively higher blood pressure in the bronchial circulation causes an increase in the capillary blood flow, leading to extravasation of erythrocytes (i.e. alveolar hemorrhage). If this hemorrhage cannot be resorbed, it results in tissue necrosis and infarction. Different definitions of pulmonary infarction are used in literature (clinical, radiological and histological), although the diagnosis is nowadays mostly based on radiological characteristics. Notably, the infarcted area is only replaced by a fibrotic scar over a period of months. Hence and formally, the diagnosis of pulmonary infarction cannot be confirmed upon diagnosis of acute PE. Little is known of the impact and relevance of pulmonary infarction in acute PE, and whether specific management strategies should be applied to prevent and/or treat complications such as pain, pneumonia or post-PE syndrome. In this review we will summarize current knowledge on the pathophysiology, epidemiology, diagnosis and prognosis of pulmonary infarction in the setting of acute PE. We highlight the need for dedicated studies to overcome the current knowledge gaps.
Epidemiology, patterns of care and mortality for patients with hemodynamically unstable acute symptomatic pulmonary embolism
2018, International Journal of Cardiology
Limited information exists about the epidemiology, management and outcomes of hemodynamically unstable patients with acute pulmonary embolism (PE). We aimed to evaluate the prevalence and outcomes of unstable PE, and to assess the acute management in routine clinical practice.
This study included 34,380 patients from the RIETE registry with PE between 2001 and 2016. Primary outcomes included all-cause and PE-specific 30-day mortality. We used multivariable adjustments to calculate hazard ratios among unstable patients who did and did not receive reperfusion.
Overall, 1207 patients (3.5%) presented with hemodynamic instability. All-cause 30-day mortality was 14% and 5.4% in those with versus those without hemodynamic instability (P < 0.001). Two hundred and thirty eight (20%) unstable patients received reperfusion therapy. After multivariable adjustment, reperfusion therapy was associated with non-significantly reduced 30-day all-cause mortality (hazard ratio [HR] 0.71; 95% CI, 0.45 to 1.10; P = 0.12), and significantly reduced 30-day PE-related mortality (HR 0.56; 95% CI, 0.31 to 0.99; P = 0.04). When limiting the adjusted analyses to unstable patients with right ventricular dysfunction, the difference was significant for both all-cause (HR 0.65; 95% CI, 0.42 to 1.00; P = 0.05) and PE-related mortality (HR 0.52; 95% CI, 0.30 to 0.92; P = 0.02).
In a multinational registry of patients with PE, prevalence of hemodynamic instability was 3.5%, with high associated 30-day mortality rates. Although use of reperfusion was associated with lower mortality rates, particularly in patients with right ventricular dysfunction, it was used in only a fifth of patients.
Clinical relevance of syncope in patients with pulmonary embolism
2018, Thrombosis Research
Citation Excerpt :
The common symptoms of PE include dyspnea, chest pain, and hemoptysis [2], and syncope is an unusual clinical manifestation associated with this condition. Syncope has been reported to occur in 5.5–16% of patients with PE, depending upon the study design and the population in which these findings were noted [2–11]. Data regarding the incidence of syncope in Asian patients with PE are lacking.
Syncope is an unusual clinical manifestation of pulmonary embolism (PE), and the clinical significance of syncope in PE patients remains controversial. We investigated the incidence of syncope, examined the clinical factors associated with syncope, and assessed the association between syncope and the short-term outcomes of PE.
We retrospectively classified patients presenting with PE into 2 groups: patients with syncope and those without syncope. We compared the clinical and computed tomography parameters between the groups.
Among 1084 patients diagnosed with PE, 45 (4.2%) presented with syncope. Four patients which presented with cardiac arrest were excluded from the study. The syncope group showed significantly higher blood biomarker levels and higher rates of central PE and right ventricular dilation than the control group. Unprovoked PE (odds ratio [OR] 8.046, 95% confidence interval [CI] 3.073–21.069, p < 0.001), female sex (OR 3.419, 95% CI 1.348–8.675, p = 0.010), central PE (OR 2.854, 95% CI 1.298–6.278, p = 0.009), and troponin I level (OR 2.812, 95% CI 1.765–4.480, p < 0.001) were observed to be independent factors associated with syncope in PE patients. However, multivariate analysis showed that the presence of syncope was not a significant predictor of adverse outcomes and recurrent venous thromboembolism in PE patients.
Although syncope is associated with a more severe form of PE, it does not influence the short-term prognosis of PE. Central PE, blood troponin I level, unprovoked PE, and female sex were observed to be clinical factors related with syncope in patients with PE.
The prognostic impact of chest pain in 1306 patients presenting with confirmed acute pulmonary embolism
2016, International Journal of Cardiology
Citation Excerpt :
It has been hypothesised that occlusion of smaller, peripheral pulmonary arteries more frequently lead to pulmonary infarction due to inability of the smaller pulmonary arterial bed to accommodate systemic arterial inflow from bronchial anastomoses, resulting in extravasation of red blood cells into the alveoli and subsequent infarction [10]. However, whether pulmonary infarction carries independent prognostic value has been disputed amongst different studies [11,12]. More specifically, the prognostic significance of the symptom of chest pain in acute PE has never been defined.
The prognostic influence of chest pain in patients presenting with pulmonary embolism has not been well defined. We investigated whether the presence of chest pain at presentation affected the mortality of patients with acute pulmonary embolism.
Retrospective cohort study of consecutive patients admitted to a tertiary hospital with confirmed acute pulmonary embolism from 2000 to 2012, with study outcomes tracked using a state-wide death registry.
Of the 1306 patients included in the study, 771 (59%) had chest pain at presentation. These patients were younger with fewer comorbidities, and had lower 6-month mortality compared to patients without chest pain (5% vs 15%, P < 0.001). Chest pain was consistently found to be an independent predictor of 6-month mortality in three separate multivariable models (range of hazard ratios 0.52–0.60, all with P < 0.05). The addition of chest pain to a multivariable model that included the simplified pulmonary embolism severity index, haemoglobin, and sodium led to a significant net reclassification improvement of 18% (P < 0.001).
Chest pain is a novel, favourable prognostic marker in patients with acute pulmonary embolism.
Right bundle branch block and S<inf>I</inf>Q<inf>III</inf>-type patterns for risk stratification in acute pulmonary embolism
2016, Journal of Electrocardiology
Risk stratification in acute pulmonary embolism (PE) is crucial for identification of patients with poor prognosis. We aimed to investigate the ECG alterations of right bundle branch block (RBBB) and S_IQ_III-type patterns for risk stratification in acute PE.
Retrospective analysis of PE patients, treated in the Internal Medicine Department, was performed. Patients with RBBB and/or S_IQ_III-type were compared with those without both patterns. Logistic regression models for association between these ECG alterations and respectively right ventricular dysfunction (RVD), high-risk PE status and myocardial injury were computed.
175 patients were included for this retrospective analysis. Total study sample comprised 37 PE patients (21.1%) with RBBB and/or S_IQ_III-type patterns and 138 PE patients (78.9%) without both signs.
Heart rate (97.4 ± 17.2 vs. 93.2 ± 26.8/min, P = 0.021), cardiac troponin I values (0.19 ± 0.38 vs. 0.11 ± 0.24, P = 0.003) and percentage of patients with RVD (83.9% vs. 52.7%, P = 0.005) were significantly higher in PE patients with RBBB and/or S_IQ_III-type patterns compared to PE patients without both ECG alterations.
Multi-variate logistic regression models adjusted for age and gender revealed significant associations between RBBB and RVD (OR3.942, 95% CI1.054–14.747, P = 0.042) and between S_IQ_III-type patterns and RVD (OR5.667, 95% CI1.144–28.071, P = 0.034). The association between RBBB and cardiac injury (cTnI > 0.4 ng/ml) (OR2.531, 95% CI 0.973–6.583, P = 0.06) showed a borderline significance, while the association between S_IQ_III-type patterns and cardiac injury was significant (OR3.956, 95% CI1.309–11.947, P = 0.015).
RBBB and S_IQ_III-type patterns were both associated with RV overload and cardiac injury. RBBB and S_IQ_III-type patterns were connected with 3.9-fold and 5.7-fold elevated risk of RVD, respectively.
Syncope and collapse in acute pulmonary embolism
2016, American Journal of Emergency Medicine
Syncope and collapse (= presyncope) are 2 symptoms of pulmonary embolism (PE), which are suspected of being connected with poorer outcome, regardless of haemodynamic instability. However, pathomechanisms are not completely understood. We aimed to investigate these pathomechanisms in regard to blood pressure and heart rate of syncope/collapse in PE.
We performed a retrospective study of consecutive PE patients, who were treated in the Internal Medicine Department. Patients with and without syncope/collapse were compared. Regression models for associations between syncope/collapse and blood pressure, heart rate and shock index (SI) were computed. Moreover we calculated ROC analyses and Youden indices for effectiveness and cut-off-values of these parameters for the probability of syncope/collapse.
182 patients (mean-age 68.5 ± 15.3 years; 61.5% female) with confirmed PE were included in this study. 20 PE patients (11.0%) showed a syncope/collapse.
PE patients with syncope/collapse were in median 7.5 years older (78.5 (72.0/82.3) vs. 71.0 (61.0/80.0) years, P = .0575), had lower systolic (132.0 (108.8/154.0) vs. 145.5 (127.0/166.0) mmHg, P = .0845) and diastolic (70.0 ± 27.0 vs. 78.4 ± 18.4 mmHg, P = .0740) blood pressure, whereas heart rate (103.5 (87.8/116.0) vs. 90.0 (76.0/102.0)beats/min, P = .0518), SI (0.78 (0.65/1.01) vs. 0.60(0.50/0.79), P = .0127) and frequency of right ventricular dysfunction (RVD) (88.2% vs. 55.8%, P = .0294) were higher in PE patients with syncope/collapse than in those without.
Hypotension (systolic blood pressure < 90 mmHg), tachycardia and SI > 1.0 were connected with 6.4-fold, 2.5-fold and 5.8-fold higher probability of syncope/collapse, respectively. ROC analyses revealed cut-off values of ≤ 110 mmHg, ≥ 107beats/min and > 0.62 for systolic blood pressure, heart rate and SI with low AUC values, respectively.
The pathomechanism of syncope/collapse in patients with acute PE seems to be connected with blood pressure fall, heart rate increase and RVD, in terms of cardiovascular syncope with reduced cardiac output and vasovagal reflex.

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Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

Drs. Lobo, Zorrilla, Aizpuru, Uresandi, Conget, Garcia-Bragado, and Monreal have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

RIETE was supported by an unrestricted educational grant from Sanofi-Aventis.

This project has been partially supported by Red Respira, Instituto Carlos III (RedRespira-ISCiii-RTIC-03/11).

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Chest

Original Research: Venous Thromboembolic DiseaseClinical Syndromes and Clinical Outcome in Patients With Pulmonary Embolism: Findings From the RIETE Registry

Introduction

Patients and methods

Results

Conclusions

Section snippets

Inclusion and Exclusion Criteria

Results

Discussion

Members of the RIETE Group

ACKNOWLEDGMENT

Am J Cardiol

Chest

Chest

Am J Cardiol

J Vasc Surg

J Thromb Haemost

Chest

Am J Med

Original Research: Venous Thromboembolic Disease
Clinical Syndromes and Clinical Outcome in Patients With Pulmonary Embolism: Findings From the RIETE Registry