Acute Pulmonary Embolism Is An Independent Predictor of Adverse Events in Severe Decompensated Heart Failure
Darze ES, Latado AL, Guimaraes AG, Guedes RAV, Santos AB, de Moura SS, Passos CS. Chest: First published online on March 30, 2007.
ABSTRACT: Background: Congestive heart failure CHF is a well-recognized risk factor for venous thromboembolism VTE and is associated with a higher mortality in patients with an acute pulmonary embolism PE. There are very few data on how an acute PE affects the clinical course of heart failure patients. The purpose of this study was to determine the impact of an acute PE on the short-term prognosis of patients hospitalized for decompensated CHF. Methods: This was a prospective cohort study of 198 patients admitted to a Coronary Care Unit between July 2001 and March 2003 with severe decompensated CHF. The primary outcome measure was death or re-hospitalization at 3 months. Results: Pulmonary embolism was confirmed in 18 of 198 patients enrolled 9.1%. The groups with and without PE were comparable with regards to demographics, the prevalence of comorbid conditions and severity of CHF p>0.05. The prevalence of cancer p=0.0001, previous VTE p=0.003 and right ventricular overload p=0.006 was higher in the PE group. The presence of PE was also associated with a longer hospital stay 37.5 ± 71.6 days versus 15.4 ± 15.0 days, p=0.001 and a higher incidence of death or re-hospitalization at 3 months 72.2% vs. 43.9%, p=0.02. In a multiple logistic regression analysis PE remained an independent predictor of death or re-hospitalization at 3 months OR 4.0, IC 95% 1.1-15.1; p=0.038. Conclusions: Acute pulmonary embolism commonly complicates the hospital course of severe CHF patients, increasing the length of hospital stay and the chance of death or re-hospitalization at 3 months.
Acute Pulmonary Embolism Predicts Death in Patients with Congestive Heart Failure
Review by Ranjith Shetty, MD
Congestive heart failure (CHF) is a risk factor for venous thromboembolism (VTE), and these two illnesses commonly occur together in hospitalized patients. This prospective study was performed to determine the effects of pulmonary embolism (PE) on the morbidity and mortality of patients with severe CHF over a three-month period. Consecutive patients enrolled into a coronary care unit with a diagnosis of CHF were evaluated for inclusion in the study. Patients were excluded if they had an acute ST segment elevation MI or if they had a primary admitting diagnosis other than CHF. The primary endpoints were death or re-hospitalization at 3 months. The secondary endpoint was death and/or re-hospitalization.
The study included 198 patients. PE was confirmed in 18 (9.1%) patients. Both groups of CHF patients with and without PE had a high prevalence of severe left ventricular function (38.9% versus 42.1%, p=0.79) and poor functional class at baseline (NYHA III/IV 55.6% versus 55.0%, p=0.96). Cancer (p = 0.0001), previous VTE (p = 0.003) and immobilization (p = 0.018) occurred more frequently in the PE group. Right ventricular overload was also significantly more common in the PE group (p = 0.006).
At 3 months, the PE group presented with higher mortality (50.0% versus 30.6%, p = 0.09) and re-hospitalization rates (58.3% versus 24.1%, p =0.01). The combined endpoint of death or re-hospitalization was higher in the CHF group with PE (72.2% versus 43.9%, p = 0.02). PE was an independent predictor for the combined endpoint of death and re-hospitalization at 3 months in a multiple logistic regression analysis (OR 4.0; 95% CI 1.1 – 15.1; p=0.038).
PE worsens outcomes in patients with CHF. Patients with CHF are at risk for VTE, and PE has important pathophysiological implications on patients with congestive heart failure. Acute PE leading to right ventricular overload in patients with poor cardiac reserves can lead to worsening cardiac function and increasing morbidity and mortality in these patients. Further studies need to be done in this population to evaluate prophylaxis and diagnostic algorithms in these high-risk patients to prevent the long-term consequences CHF and PE.
About Ranjith Shetty, MD: Dr. Shetty completed his internship and residency in internal medicine at Georgetown University. In July of 2007, Dr. Shetty will begin his Cardiology fellowship at the Medical College of Virginia in Richmond, VA. He is currently involved with investigator initiated and multi-center trials at Brigham and Women’s hospital looking at novel anticoagulant treatment strategies for venous thromboembolism, as a Venous Thromboembolism Research Group Fellow.