Impact of pre-existing heart failure on outcomes after pulmonary embolism: a prospective registry study
K Gjuras, A Patrk, I JurinAbstract
Background
Pulmonary embolism (PE) remains a major cause of cardiovascular morbidity and mortality. According to available literature, heart failure (HF) is associated with adverse short-term outcomes after PE; however, studies directly comparing short- and especially long-term outcomes between patients with and without pre-existing HF are scarce.
Purpose
To evaluate short-term and long-term outcomes after PE in patients with a history of HF compared with those without HF.
Methods
We analysed a prospective registry of adult patients with objectively confirmed PE treated in two tertiary centres between December 2013 and December 2024. PE was diagnosed using multislice computed tomography pulmonary angiography, and all patients received guideline-based management. Post-acute and discharge anticoagulation consisted of vitamin K antagonists, direct oral anticoagulants (DOACs), or heparin. Patients who died during the index hospitalisation were excluded. Patients were categorised into the HF group and the no-HF group. The primary outcome was 30-day and long-term all-cause mortality. Secondary outcomes included recurrent venous thromboembolism (VTE) and major bleeding. Survival was assessed using Kaplan–Meier analysis and Cox multivariable regression.
Results
A total of 773 patients were included: 175 (22.6%) in the HF group and 598 (77.4%) in the no-HF group, with a median follow-up of 36.3 months. Overall, 56.3% were women; HF was more prevalent in women (27.4% vs 16.6%, p < 0.001). Median age was 72 years [60–80], with HF patients being older (80 vs 69 years, p < 0.001). The HF group received DOACs less frequently (33.1% vs 42.3%, p = 0.046) and had higher Pulmonary Embolism Severity Index (PESI; 123 vs 92) and HAS-BLED (3 vs 1) scores (both p < 0.001); median left ventricular ejection fraction was 45% vs 60% (p < 0.001). Thirty-day mortality was significantly higher in the HF group (9.7% vs 2.7%, p < 0.001). Long-term mortality occurred in 131 patients (74.9%) in the HF group compared with 239 patients (40.0%) in the no-HF group (p < 0.001). Recurrent VTE was less frequent in patients with HF (14.9% vs 25.3%, p = 0.004), whereas major bleeding tended to be more common (9.8% vs 5.5%, p = 0.054). In unadjusted analysis, HF was associated with impaired long-term survival (HR 2.69, 95% CI 2.17–3.34). This association persisted after adjustment for age and sex (HR 1.58, 95% CI 1.26–1.98) and in a separate model accounting for discharge anticoagulation, PESI, and HAS-BLED scores (HR 1.56, 95% CI 1.23–1.97).
Conclusion
In this prospective cohort, pre-existing HF was associated with substantially worse long-term outcomes after PE, with a more than 50% increase in long-term mortality across distinct multivariable models. These findings suggest that a history of HF identifies a high-risk phenotype among patients surviving the acute phase of PE and should be considered in long-term risk stratification and follow-up strategies.Survival analysisFor image description, please refer to the figure legend and surrounding text.