Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry.
OBJECTIVE
The present study investigated current management strategies as well as the clinical course of acute major pulmonary embolism.


BACKGROUND
The clinical outcome of patients with acute pulmonary embolism who present with overt or impending right heart failure has not yet been adequately elucidated.


METHODS
The 204 participating centers enrolled a total of 1,001 consecutive patients. The inclusion criteria were based on the clinical findings at presentation and the results of electrocardiographic, echocardiographic, nuclear imaging and cardiac catheterization studies.


RESULTS
Echocardiography was the most frequently performed diagnostic procedure (74%). Lung scan or pulmonary angiography were performed in 79% of clinically stable patients but much less frequently in those with circulatory collapse at presentation (32%, p < 0.001). Thrombolytic agents were given to 478 patients (48%), often despite the presence of contraindications (193 [40%] of 478). The frequency of initial thrombolysis was significantly higher in clinically unstable than in normotensive patients (57% vs. 22%, p < 0.001). Overall in-hospital mortality rate ranged from 8.1% in the group of stable patients to 25% in those presenting with cardiogenic shock and to 65% in patients necessitating cardiopulmonary resuscitation. Major bleeding was reported in 92 patients (9.2%), but cerebral bleeding was uncommon (0.5%). Finally, recurrent pulmonary embolism occurred in 172 patients (17%).


CONCLUSIONS
Current management strategies of acute major pulmonary embolism are largely dependent on the degree of hemodynamic instability at presentation. In the presence of severe hemodynamic compromise, physicians often rely on the findings of bedside echocardiography and proceed to thrombolytic treatment without seeking further diagnostic certainty in nuclear imaging or angiographic studies.
Kasper
W
W
St. Josefs-Hospital, Wiesbaden, Germany. joho.kardio@wiesbaden.med.de
Konstantinides
S
S
Geibel
A
A
Olschewski
M
M
Heinrich
F
F
Grosser
K D
KD
Rauber
K
K
Iversen
S
S
Redecker
M
M
Kienast
J
J
D000208:Acute Disease; D000368:Aged; D003952:Diagnostic Imaging; D004452:Echocardiography; D005260:Female; D005858:Germany / Q000453:epidemiology; D006439:Hemodynamics; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D012042:Registries; D012770:Shock, Cardiogenic / Q000150:complications / Q000401:mortality; D016019:Survival Analysis; D015912:Thrombolytic Therapy; D016896:Treatment Outcome; D018497:Ventricular Dysfunction, Right / Q000150:complications / Q000503:physiopathology