Objectives

Right ventricular (RV) dysfunction (RVD) is considered as an important predictor of hemodynamic decompensation in patients with PE. The role of fibrinolytic therapy in PE patients without systemic hypotension is discussed controversially, but tended not to be recommended due to a high bleeding risk. However, we aimed to investigate the use and benefit of systemic thrombolysis in a large nationwide sample.

Methods

We analyzed data on the characteristics, comorbidities, treatments and in-hospital outcomes for all patients with acute PE (ICD-code I26) stratified for RVD in Germany between 2005 and 2017 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005-2017, own calculations).

Results

Between January 2005 and December 2017, 1,174,196 patients with acute PE (53.5% females) were included in this analysis; of those, 334,822 (28.5%) were additional diagnosed with an RVD. Patients with RVD were older than patients without RVD (74 [IQR, 63-81] vs. 72 [60-80] years, P<0.001) and showed more frequently important comorbidities including cardiovascular diseases such as coronary artery disease (14.6% vs. 13.4%, P<0.001) and atrial fibrillation (18.9% vs. 13.8%, P<0.001), but also COPD (11.1% vs. 9.9%, P<0.001), renal insufficiency (26.3% vs. 18.8%, P<0.001) and diabetes mellitus (20.6% vs. 17.8%, P<0.001). Overall, 11,4% of patients with acute PE and RVD received systemic thrombolysis. As expected, PE patients with RVD had a higher mortality rate (31.5% vs. 9.5%, P<0.001) compared to PE patients without confirmed in the multivariate logistic regression model (OR, 4.4 [95% CI, 4.3-4.5], P<0.001). Although trends analyses demonstrating a higher use of systemic thrombolysis (β 0.33 [95%CI 0.36 to 0.44], p<0.001) between 2005 and 2017, the rate of intracerebral bleeding events remained almost unchanged (β -0.02 [95%CI -0.18 to 0.13], p=0.797) and the mortality rate (β -0.29 [95%CI -0.30 to -0.21], p<0.001) decreased in the same time period. Among haemodynamically stable patients with acute PE and RVD, the administration of systemic thrombolysis was associated with a lower risk of in-hospital mortality (OR, 0.65 [95% CI, 0.62-0.68], P<0.001) compared to PE patients with RVD and no reperfusion treatment.

Conclusion

In conclusion, the data from the German nationwide inpatient sample highlight a clear association between RVD and in-hospital mortality in patients with acute PE. Among haemodynamically stable patients with RVD, systemic thrombolysis was beneficial regarding in-hospital survival. Despite a higher use of systemic thrombolysis, events of intracerebral bleeding events remained almost unchanged.