Contemporary Management and Clinical Course of Acute Pulmonary Embolism: The COPE Study

Abstract

Background. New diagnosis, risk stratification and treatment strategies became recently available for patients with acute pulmonary embolism (PE) leading to changes in clinical practice and potentially influencing short-term patients’ outcomes. Research question. The COntemporary management of PE (COPE) study is aimed at assessing the contemporary clinical management and outcomes in patients with acute symptomatic PE. Study design and Methods Prospective, non-interventional, multicentre study. The co-primary study outcomes, in-hospital and 30-day death, were reported overall and by risk categories according to the ESC and AHA guidelines. Results Among 5,213 study patients, PE was confirmed by computed tomography in 96.3%. In-hospital, 289 patients underwent reperfusion (5.5%), 92.1% received parenteral anticoagulants; at discharge, 75.6% received direct oral anticoagulants and 6.7% vitamin K antagonists. In-hospital and 30-day mortality were 3.4% and 4.8%, respectively. In-hospital death occurred in 20.3% high-risk patients (n=177), in 4.0% intermediate-risk patients (n=3281) and in 0.5% low-risk patients (n=1702) according to ESC guidelines. Further stratification in intermediate-high and intermediate-low risk patients did not reach statistical significance; intermediate-risk patients with sPESI>0 alone had lower mortality compared to those with one or both among RVD at echocardiography or increased troponin. Death or clinical deterioration occurred in 1.5%, 5.0% and 9.4% of patients at low, intermediate-low and intermediate-high risk for death according to ESC guidelines. Interpretation. For the majority of patients with PE, contemporary initial management includes risk stratification and treatment with direct oral anticoagulants. In-hospital mortality remains high in intermediate and high-risk patients calling for and informing research focused on its reduction.

Thrombosis and Haemostasis 2023 Editors' Choice Papers

“…These encompass critical aspects, including gender disparities, the impact of obesity, previous thrombotic events, and the influence of various medical conditions like cancer. These factors have been under investigation of the Italian COPE study's report, 37 potentially the most extensive and contemporary on pulmonary embolism (PE) with over 5,000 patients from more than 180 sites and which should serve as a valuable data source on current disease patterns, management strategies, and outcomes of acute PE.…”

Direct Oral Anticoagulants for Pulmonary Embolism

“…29 30 In a recent prospective cohort study, only 1.2% of PE patients were directly discharged from the emergency department, while 5.8% were discharged early from the hospital, within 48 hours. 31…”

“…Recent registries have shown that about 60 to 70% of patients with acute PE qualify for intermediate risk of early death (in-hospital or after 30 days), defined as a hemodynamic stability associated an RV dysfunction and/or troponin alteration according to the guidelines of the European Society of Cardiology or the American Heart Association. 11 31 35 The expected mortality in these normotensive patients with clinical risk factors for death (PESI III–V or sPESI ≥ 1) and/or evidence of RV overload by imaging or by increased troponin varies between 2 and 15% in the short term. Among patients included in this wide risk category, there is a subgroup with a considerable risk of requiring rescue reperfusion or cardiopulmonary resuscitation for clinical deterioration.…”

“…According to the European Society of Cardiology, the combination of PESI III to V or sPESI ≥ 1, RV dysfunction at imaging and increased troponin identify a subgroup of about 25% of all PE patients having a short-term mortality as high as 10 to 15%. 31 32 33 34 35 36 In addition to the uncertainties on the criteria for identification of the intermediate- to high-risk patients, the optimal regimen of anticoagulation for these patients in the initial phase is also unknown. 31 37 38 The European Society of Cardiology guidelines still recommend the use of unfractionated heparin for intermediate- to high-risk patients in the early phase of anticoagulation 11 ; LMWH could be an alternative to avoid the need for monitoring and to promptly guarantee therapeutic anticoagulation.…”

Prevalence of and Eligibility for Surveillance Without Anticoagulation Among Adults With Lower-Risk Acute Subsegmental Pulmonary Embolism

“…Pulmonary embolism (PE) confined to the subsegmental pulmonary arteries, known as subsegmental PE, has increased in prevalence as detection capacities of computed tomography pulmonary arteriography (CTPA) have improved. Approximately 3% to 12% of PEs diagnosed using CTPA are subsegmental . The pharmacological treatment of patients with low-risk subsegmental PE is contested .…”