Clinical phenotypes and risk of early hemodynamic deterioration in intermediate-high-risk patients with acute pulmonary embolism
Marco Zuin a) b) c), Gregory Piazza d) e), Gianluca Rigatelli c), Amedeo Bongarzoni f), Iolanda Enea g), Franco Casazza h), Claudio Picariello i), Claudio Bilato j), Loris Roncon k)
a) Department of Translational Medicine, University of Ferrara, 44124 Ferrara, Italy
b) Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, 35122 Padua, Italy
c) Division of Cardiology, South Padova General Hospitals, 35043 Monselice, Italy
d) Thrombosis Research Group, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States of America
e) Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
f) Department of Cardiology, ASST Santi Paolo e Carlo, University of Milan, 20142 Milano, Italy
g) Internal and Emergency Medicine, Maddaloni Hospital, Caserta, Italy
h) Department of Cardiology, San Carlo Borromeo Hospital, Milano, Italy
i) Department of Cardiology, S. Maria della Misericordia Hospital, Rovigo, Italy
j) Department of Cardiology, West Vicenza Hospital, Arzignano, Vicenza, Italy
k) Cardiologia, Casa di Cura Città di Rovigo, Rovigo, Italy
Abstract
Introduction
Intermediate-high-risk pulmonary embolism (PE) patients face elevated risks of sudden clinical deterioration in early hours after symptoms onset. We performed a hierarchical cluster analysis among intermediate-high risk PE patients to identify phenotypic subgroups and assess their association with hemodynamic deterioration risk within 48 h of admission.
Methods
A post hoc analysis of patients with intermediate-high risk PE enrolled in the Italian Pulmonary Embolism Registry (ClinicalTrials.gov: NCT01604538) was performed. Hierarchical clustering (Ward’s linkage) and principal component analysis identified phenotypic clusters among a population of intermediate-high-risk PE.
Results
The study involved 420 patients with intermediate-high risk PE (mean age 72.4 ± 13.8 years, 63.8 % males). Three distinct phenotypic clusters were identified: Cluster 1, characterized by patients with systolic blood pressure between 90 and 110 mmHg, acute onset dyspnea, and right ventricular strain at ECG; Cluster 2, featuring males <65 years with pleuritic chest pain; and Cluster 3, females ≥65 years with chest pain. The rates of 48-h hemodynamic deterioration were 14.6 % in Cluster 1, 7.5 % in Cluster 2, and 4.5 % in Cluster 3. Multivariate analysis showed Cluster 1 had a significantly higher risk of deterioration compared to Clusters 2 (HR: 1.42, 95 % CI: 1.38–1.46, p < 0.001) and 3 (HR: 1.51, 95 % CI: 1.15–1.62, p = 0.01), adjusting for age, sex, and treatment.
Conclusions
Cluster analysis identified 3-statistically-identified phenotypic clusters among patients with intermediate high-risk PE with different risk of hemodynamic deterioration within 48 h from admission. Further phenotyping is warranted to inform patient care and optimize clinical trial designs.