Contemporary Management of High-Risk Pulmonary Embolism

Quick Takes

  • Patients with high-risk acute pulmonary embolism (PE) experienced higher rates of all-cause mortality (~21%) than patients with intermediate-risk PE (~4%).
  • Patients with catastrophic PE requiring vasopressors or experiencing cardiac arrest had the highest rate of all-cause mortality (42%).
  • The risk of bleeding increased alongside the risk of all-cause mortality for patients with intermediate-risk, high-risk, and catastrophic acute PE.

Study Questions:

What are the contemporary management strategies and associated outcomes in patients with high-risk pulmonary embolism (PE)?


The authors used the PERT (Pulmonary Embolism Response Team) Consortium Registry to identify patients with intermediate-risk, high-risk, and catastrophic PE. Risk was defined based on the European Society of Cardiology (ESC) classification, with catastrophic PE being defined as patients with hemodynamic collapse requiring vasopressor support or experiencing cardiac arrest. Multivariable logistic regression was used to assess association between clinical characteristics and outcomes in this high-risk population.


Among the 5,790 patients in the PERT Consortium Registry, 2,976 presented with intermediate-risk PE and 1,442 with high-risk PE. Patients with high-risk PE were more commonly treated with advanced therapies than intermediate-risk PE patients (41.9% vs. 30.2%, p < 0.001). In-hospital mortality (20.6% vs. 3.7%, p < 0.001) and major bleeding (10.5% vs. 3.5%, p < 0.001) were more common in high-risk than intermediate-risk PE patients. Predictors of in-hospital mortality include vasopressor use (odds ratio [OR], 4.56; 95% confidence interval [CI], 3.27-6.38), extracorporeal membrane oxygenation (ECMO) use (OR, 2.86; 95% CI, 1.12-7.30), clot-in-transit (OR, 2.25; 95% CI, 1.13-4.52), and malignancy (OR, 1.70; 95% CI, 1.13-2.56). Patients with catastrophic PE (n = 197, 13.7% of all high-risk PE patients) had higher in-hospital mortality rates (42.1% vs. 17.2%, p < 0.001) than those with noncatastrophic high-risk PE. ECMO (13.3% vs. 4.8%) and systemic thrombolysis (25% vs. 11.3%, p < 0.001) were also more common in catastrophic than noncatastrophic high-risk PE patients.


The authors conclude that mortality rates are high in patients with high-risk PE. They also conclude that patients with catastrophic PE (hemodynamic collapse) have the highest rate of in-hospital mortality.


PE is commonly seen as an acute condition with a high risk for adverse cardiac events. This multicenter registry analysis identifies that patients with high-risk PE, as defined by the ESC criteria, are the primary driver of short-term all-cause mortality risk among patients with acute PE, with a mortality rate of about 20%. That risk is even higher among patients who require vasopressor support or experience cardiac arrest, coined “catastrophic PE” (~40%). This elevated risk of death was mirrored by an increased risk of major bleeding in high-risk and catastrophic-risk patients (8.4% and 24.8%, respectively), complicating the use of thrombolytic-based therapies. Despite advances in catheter-based therapies and ECMO for patients with acute PE, the all-cause mortality rates continue to be quite high. As such, research is needed to better define specific therapies that can improve PE-related outcomes.

Clinical Topics: Vascular Medicine

Keywords: Pulmonary Embolism

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