Pulmonary Embolism in anticoagulated patients: a retrospective single-centered cohort comparing data from the PIOPED II study
R Brandao, A R Tomas, C Silva, M Roxo Rosa Iglesias, C Chumbo, D MadeiraAbstract
Introduction
Pulmonary embolism (PE) is a prevalent and potentially fatal condition representing the third most frequent acute cardiovascular syndrome with an incidence reaching 115/100000 individuals annually. Although uncommon, cases of acute PE have been reported in patients undergoing anticoagulation (AC).
Objectives
Review the characteristics of PE in patients receiving AC and compare these findings with data from individuals not under this treatment.
Methods
We conducted a retrospective single-center study including patients diagnosed with PE from January 2019 to December 2023 in medical wards of our hospital with 18 years or older. Patients whose PE did not represent a current diagnosis were excluded. Socio-demographic data, comorbidities, pharmacological treatments, and clinical outcomes were collected. Moreover, the findings were compared with data from the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) study which included only patients not undergoing AC therapy.
Results
Of the 1197 patients evaluated, 74 were excluded and 59 (7%) were anticoagulated at the time of PE diagnosis, mostly with direct oral anticoagulants (DOACs) (78%), specifically rivaroxaban (43%) or apixaban (33%), at appropriate doses, though 19% reported non-compliance. The mean age was 76±13 years vs. 57±17 in PIOPED II (p < 0,001). In the AC group, most PE were segmental (54%) but in PIOPED II there was a predominance of lobar PEs (77%) (p < 0,001). The most frequently reported signs and symptoms in both groups were dyspnea (56% in the AC group vs. 79% in PIOPED II), chest pain (27% vs. 64%), cough (37% vs. 43%), tachypnea (68% vs. 57%), tachycardia (81% vs. 26%), and respiratory failure (51% vs. 21%). SARS-CoV-2 infection (34%), previous venous embolism (25%), obesity (25%), immobilization (20%) and active cancer (19%) emerged as the most common risk factors (RF) in our cohort. Some patients had no identifiable RF (10% in our study and 6% in PIOPED II). Mortality in our study reached 29%, but equivalent data from PIOPED II was not available.
Conclusion
PE in anticoagulated patients appears to occur in older individuals and in smaller pulmonary artery branches. This population does not exhibit a significantly different prevalence of symptoms or RF, and events may arise even in their absence. The low overall incidence of PE in anticoagulated patients and the predominance of segmental involvement suggests that current treatment strategies remain effective, potentially resulting in less severe outcomes. Due to lack of studies and consensus in literature, patient’s management is most often not evidence based. Further and larger studies are needed to identify high risk scenarios and to implement strategies such as DOAC level measurement to better predict recurrence, understand underlying mechanisms of treatment failure and guide appropriate approaches.