Pulmonary embolism mortality has declined over the last twenty years, reflecting true prognostic improvement across ESC risk categories

Background

A decline in short-term mortality from acute pulmonary embolism (PE) has been reported over the last two decades. However, it remains debated whether this trend reflects true prognostic improvement or is mainly driven by increased diagnosis of low-risk patients due to the widespread use of multidetector CT pulmonary angiography. We investigated temporal trends in PE-related mortality across European Society of Cardiology (ESC)-defined risk categories.

Methods

We analyzed consecutive patients with confirmed acute PE enrolled over four guideline periods (2000–2008, 2009–2014, 2015–2019, and 2020–2024). Risk stratification followed ESC definitions: low risk (sPESI = 0), intermediate risk (sPESI > 0 in the absence of shock), and high risk (hemodynamic instability or shock). The primary outcome was 30-day PE-related mortality. Temporal trends were assessed using cumulative hazard estimates and Cox proportional hazards models.

Results

A total of 2,536 patients were included. Over time, the proportion of low-risk patients increased, consistent with broader diagnostic strategies, while intermediate-risk patients remained the predominant group.

At 30 days, 73 PE-related deaths (2.9%) were observed overall. Thirty-day PE-related mortality declined over successive guideline periods, from 4.2% (17/401) in 2000–2008 to 2.4% (16/673) in 2009–2014, 2.8% (18/643) in 2015–2019, and 2.7% (22/819) in 2020–2024.

Importantly, the reduction in mortality was not limited to low-risk patients. Declining mortality trends were observed across all ESC risk categories, including intermediate- and high-risk patients. Cox proportional hazards analysis confirmed a significant temporal reduction in PE-related mortality (global likelihood ratio χ² = 11.0, p = 0.012), indicating improved outcomes independent of baseline risk distribution (Figure 1).

Conclusions

Over the last twenty years, short-term mortality from acute pulmonary embolism has declined across all ESC-defined risk categories. This finding suggests a true improvement in PE prognosis probably due to increased disease awareness, quality of treatment and global care and cannot be explained solely by increased diagnosis of low-risk patients.Figure 1 For image description, please refer to the figure legend and surrounding text.