Prognosis

Most cases of pulmonary embolism (PE) resolve. Some patients may experience “post-PE syndrome”, which consists of one or more symptoms of chest discomfort, dyspnea or exercise intolerance.[294]​ Chronic thromboembolic disease (CTED) refers to unresolved perfusion abnormalities on imaging following completion of at least 3 months of anticoagulant therapy. CTED and post-PE syndrome may coexist, but patients may experience one without the other. The most serious long-term sequelae of PE is chronic thromboembolic pulmonary hypertension, in which CTED is associated with pulmonary arterial hypertension and right heart abnormalities. This complication occurs in 3% to 5% of patients after acute PE and has several management options.[295]

The Pulmonary Embolism Severity Index (PESI) and simplified Pulmonary Embolism Severity Index (sPESI) classify patients with confirmed PE without shock or hypotension into categories associated with increasing 30-day mortality.[3]​​​[124] Studies indicate that PESI and sPESI predict short-term mortality with comparable accuracy, but the latter is easier to use.[205][206]​ Using sPESI, patients in the high-risk category have a short-term mortality of 10.9%, while patients in the low-risk category have 30-day mortality of 1%.

Mortality is often due to cardiogenic shock secondary to right ventricular (RV) collapse. One systematic review and meta-analysis of 3283 hemodynamically stable patients with acute PE found that the risk of short-term mortality was significantly greater in those with RV dysfunction than those without RV dysfunction (odds ratio 2.29, 95% CI 1.61 to 3.26).[296] In-hospital or 30-day mortality was reported in 167 of 1223 patients (13.7%) with RV dysfunction and in 134 of 2060 patients (6.5%) without RV dysfunction.[296]

Registry data confirm that, in patients with acute PE, hypotension (systolic BP <90 mmHg) is associated with increased mortality.[297] Of the 1875 patients enrolled in the prospective observational Emergency Medicine Pulmonary Embolism in the Real World Registry, all-cause inpatient mortality (13.8% vs. 3.0%, P <0.001) and 30-day mortality (14.0% vs. 1.8%, P <0.001) were significantly greater among the 58 patients with hypotension than those without.[297] In the international prospective Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry, the 90-day mortality rate for the 248 patients with symptomatic PE with hypotension (systolic BP <90 mmHg) was 9.27%, compared with 2.99% for patients with symptomatic nonmassive PE.[123]

Recurrence

Consensus guidelines recommend 3 months of oral anticoagulant therapy, unless contraindicated by bleeding, in all patients with venous thromboembolism (VTE) with reassessment for possible extended therapy after the initial 3 months of treatment.[278]​ Patients with VTE occurring in the setting of a major or minor transient provocation will usually stop anticoagulants after completion of at least 3 months of therapy. Consideration should be given to indefinite treatment among patients who have idiopathic or unprovoked VTE.[298] Patients with cancer continue anticoagulants, as long as they are tolerated, while the cancer is active, and if the risk of bleeding remains low to moderate without any recent major bleeding episodes.[19]​ Regular reassessment is necessary in patients with cancer as the risks of VTE and bleeding regularly change given modifications in pharmacotherapeutic, surgical, and radiation therapies.[20][46]

Many studies have attempted to identify subgroups of patients with unprovoked VTE who do not need to be treated indefinitely with oral anticoagulation. There is strong evidence that the risk of recurrent VTE is higher in the following patients: male sex; those with a diagnosis of a proximal deep vein thrombosis (DVT) (versus isolated calf DVT); those with ultrasound evidence of residual clot; those who have an elevated D-dimer 1 month following stopping a 3- to 6-month course of oral anticoagulation; and those who had an unprovoked VTE.[19][45]​​ Several risk assessment models have been developed for this purpose, including the DASH score, the Vienna Prediction Model, and the “Men Continue and HER-DOO2” model.[261]​ The latter model identifies a subset of women with low risk for recurrent VTE after an initial unprovoked event, and a prospective validation study of this model was published.[262]

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