Persistent right ventricular dysfunction and hemodynamic evolution predict in-hospital deterioration in intermediate-high- and high-risk pulmonary embolism

Miguel A. Quintana, Cardiopulomonary Institute LW Randall, Cardiovascular, Asunción, Paraguay
Joaquín Perea, Sanatorio Guemes, Unidad Coronaria, Buenos Aires, Argentina
Ricardo Villarreal, Cardiopulomonary Institute LW Randall, Cardiovascular, Asunción, Paraguay; Sanatorio Guemes, Unidad Coronaria, Buenos Aires, Argentina
Mauricio Soto, Hospital Hernán Henríquez Aravena, Cardiología, Temuco, Chile
Marildes Castro, Faculdade de Medicina, Universidade Federal de Minas Gerais, Cardiologia,Belo Horizonte, MG, Brazil
Rafael Cortês, Hospital Sírio, Libanês Brasília, Cardiologia, Brasília, DF, Brazil
Patricio Sanhueza, Universidad de Chile, Cardiologia, Santiago, Chile
Iván Saavedra, Biocor Hospital de Doenças Cardiovasculares Ltda, Cardiologia, Belo Horizonte, MG, Brazil
Yhaquelina Quispe, Hospital Obrero No 1, La Paz, Bolivia
Roger Tenezaca, Hospital de especialidades Guayaquil Abel Gilbert Ponton, Guayaquil, Ecuador
Roberto Colque, Sanatorio Allende, Cardiologia, Córdoba, Argentina
Alexandra Arias, Instituto Nacional de Cardiología Ignacio Chávez, State of Mexico, Mexico
Alex Rivera-Toquica, Clinica los Rosales, Risaralda, Colombia
Manuel Álvarez, Fundacion Santa Fe de Bogota, Cardiologia,Bogotá, Colombia
Ysmenia D. Pérez, Hospital General y Especialidades Dr. Mario Tolentino Dipp, Cardiologia, Santo Domingo, Dominican Republic
Paola Morejón, Clinica Guayaquil, Cardiologia, Guayaquil, Ecuador
Karina G. Fernández, Hospital de Emergencias José Casimiro Ulloa, Cardiologia, Lima, Peru
Adriana Mogollón, Centro Medico San Francisco, Cardiologia, Caracas, Venezuela
Marcelo Cardona, Hola Hospital Privado de Rosario, Cardiologia, Rosario, Argentina
Gonzalo E. Pérez, Clinica Olivos, Cardiology,Buenos Aires, Argentina
Arnaldo López-Ruiz, AdventHealth Orlando -– Department of Critical Care, Orlando, Florida, USA

Background: Risk stratification in acute pulmonary embolism (PE) is based primarily on findings obtained at hospital admission. However, whether serial assessment of right ventricular (RV) dysfunction and hemodynamic changes provides incremental prognostic value beyond the initial risk stratification remains uncertain. Objectives: To evaluate longitudinal clinical and imaging variables associated with adverse in-hospital outcomes in patients with intermediate-high- and high-risk acute PE. Methods: This prospective registry included patients with intermediate-high- and high-risk acute PE. The primary composite endpoint comprised in-hospital mortality, invasive mechanical ventilation, persistent shock or hypotension, and extracorporeal membrane oxygenation. Longitudinal variables were assessed 24-72 hours after admission. All statistical tests were two-tailed, and a p-value < 0.05 was considered statistically significant. Multivariable logistic regression models were constructed, and discriminative performance was evaluated using the area under the receiver operating characteristic curve (AUC-ROC). A prespecified missing-data analysis was performed to assess the availability of follow-up computed tomography pulmonary angiography (CTPA). Results: The primary composite endpoint occurred in 21.2% of the 151 patients, with an in-hospital mortality rate of 9.3%. Persistent RV dysfunction on follow-up CTPA (χ2 = 15.48; p < 0.001) and follow-up systolic blood pressure (SBP; p < 0.001) were the strongest individual predictors of adverse outcomes. In the longitudinal multivariable model (n = 60), persistent RV dysfunction on follow-up CTPA (OR 9.70; 95%CI, 1.96-47.89; p = 0.005) and follow-up SBP (OR 0.90; 95%CI, 0.83-0.96; p = 0.003) remained independent predictors. The model demonstrated excellent discrimination (AUC-ROC = 0.874) and adequate calibration. The missing-data analysis showed that patients without follow-up CTPA were more severely ill at baseline, consistent with a missing not at random mechanism. Conclusions: Reassessment of established risk markers during hospitalization may improve identification of patients who remain at high risk despite initial risk classification and treatment. Persistent RV dysfunction and lower follow-up SBP were independently associated with adverse in-hospital outcomes, which supports the use of dynamic risk stratification in acute PE.

Keywords: Pulmonary Embolism. Right Ventricular Dysfunction. Prognosis; Hemodynamics. Cardiogenic Shock. Reperfusion. Thrombectomy. Logistic Models.