Cancer-Associated Pulmonary Embolism in Contemporary Clinical Practice: Clinical Severity, Incidental Detection, and Early Outcomes in a Real-World Cohort

Background: The increasing use of routine oncological imaging has led to more frequent detection of incidental pulmonary embolism (PE), potentially modifying the contemporary clinical presentation of cancer-associated pulmonary embolism (CAPE). Methods: We performed a retrospective cohort study including 381 consecutive patients hospitalized with acute PE, of whom 58 had active cancer and 323 had no active malignancy. The primary endpoint was a Severe Hemodynamic Presentation Composite Endpoint (SHPCE), defined as shock, systolic blood pressure < 90 mmHg, and/or high-risk PE according to European Society of Cardiology criteria. Clinical characteristics, severity markers, management strategies, and in-hospital outcomes were compared between patients with CAPE and non-cancer PE (NCPE). Multivariable logistic regression analyses were performed to evaluate factors associated with SHPCE and incidental PE. Results: The patients with CAPE had higher PESI (129.8 ± 29.3 vs. 110.1 ± 32.3; p < 0.001) and sPESI scores (3.03 ± 0.56 vs. 2.68 ± 0.81; p < 0.001), and lower hemoglobin levels (11.7 ± 1.9 vs. 13.2 ± 1.8 g/dL; p < 0.001). Incidental PE was more frequent in CAPE than NCPE cases (13.8% vs. 1.9%; OR 8.45, 95% CI 2.81–25.39; p < 0.001). Despite their higher baseline risk scores, patients with CAPE and NCPE showed similar rates of SHPCE (12.1% vs. 17.6%; p = 0.295), ICU admission (10.3% vs. 11.5%; p = 1.000), and in-hospital mortality (10.3% vs. 11.1%; p = 0.858). In multivariable analyses, right ventricular dysfunction (RVD) showed the strongest association with SHPCE (adjusted OR 10.21, 95% CI 5.34–19.52; p < 0.001), whereas active cancer was not associated with severe presentation. Conclusions: Active cancer was associated with higher clinical risk scores and a greater prevalence of incidental PE but not with increased hemodynamic severity or adverse in-hospital outcomes. Acute PE severity appeared to be more closely related to right ventricular involvement than to cancer status, supporting a severity-based rather than cancer-based approach to risk assessment.