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Trends in Pulmonary Embolism Management and Outcomes
Study Questions:
What are the trends in management and outcomes of acute pulmonary embolism (PE) between 2001 and 2013?
Methods:
Adults with acute venous thromboembolism (including acute PE) were enrolled in the multicenter, multinational RIETE registry. For the 25,456/50,782 patients with acute PE, temporal trends in length of hospital stay and use of therapies (pharmacological and interventional) were assessed. Temporal trends in risk-adjusted rates of all-cause and PE-related 30-day mortality were assessed using multivariable regression analysis.
Results:
Among 23,858 patients with acute PE between 2001 and 2013, mean length of stay decreased from 13.6 days to 9.3 days (32% relative reduction, pn < 0.001). Use of low molecular weight heparin for initial therapy increased from 77% to 84%, while use of unfractionated heparin decreased from 22% to 8.4% (p < 0.001 for trend). Thrombolytic therapy use increased from 0.7% to 1.0% (p = 0.07 for trend) and surgical embolectomy use increased from 0.3% to 0.6% (p < 0.01 for trend). Risk-adjusted 30-day all-cause mortality rate decreased from 6.6% in 2001-2005 to 4.9% in 2010-2013 (p = 0.02 for trend). Rates of 30-day PE-related mortality decreased from 3.3% in 2001-2005 to 1.8% in 2010-2013 (p < 0.01 for trend). Among the 778/23,858 (3.3%) acute PE patients with hypotension, 30-day all-cause mortality decreased from 15.4% in 2001-2005 to 12.1% in 2010-2013 (p = 0.30 for trend). There was no change in the risk-status for acute PE patients during the study period.
Conclusions:
The authors concluded that a decrease length of stay and changes in initial anticoagulant use were accompanied by a decrease in 30-day all-cause and PE-related mortality for patients with acute PE between 2001 and 2013.
Perspective:
Using a large multinational (primarily European) registry of venous thromboembolism patients, the authors documented decreases in the use of healthcare resources (e.g., length of stay) and improved outcomes (e.g., lower all-cause mortality) over a 13-year period for acute PE patients. While exact mechanisms for these changes were not assessed in the study, the data do highlight the improving quality of acute PE care. The impact that newer direct oral anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban) and dedicated ‘PE Response Teams’ may have on hospital length of stay and mortality remains to be evaluated.
Keywords: Anticoagulants, Embolectomy, Heparin, Heparin, Low-Molecular-Weight, Hypotension, Outcome Assessment, Health Care, Pulmonary Embolism, Thrombolytic Therapy, Venous Thromboembolism, Vascular Diseases
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