Fatality rates and use of systemic thrombolysis in pregnant women with pulmonary embolism

Hobohm, Lukas; Keller, Karsten; Valerio, Luca; Áinle, Fionnuala Ní; Klok, Frederikus A.; Münzel, Thomas; Kucher, Nils; Lankeit, Mareike; Konstantinides, Stavros

doi:10.1002/ehf2.12775

Cited by 20 publications

(25 citation statements)

References 26 publications

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“…PE remains a frequent cause of death in women aged 20–50 years. Younger women are characterised by an overall low mortality and present with specific risk factors for venous thromboembolism, such as pregnancy 63 and the use of oestrogen-containing oral agents, such as the combined oral contraceptive pill. In the USA, this peak appeared to extend to older women between 2000 and 2017, possibly reflecting the increase in the mean age of mothers for all birth orders observed during the same period.…”

Section: Discussionmentioning

confidence: 99%

Age-sex specific pulmonary embolism-related mortality in the USA and Canada, 2000–18: an analysis of the WHO Mortality Database and of the CDC Multiple Cause of Death database

Barco

Valerio

Ageno

et al. 2021

The Lancet Respiratory Medicine

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146

105

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Background Pulmonary embolism (PE)-related mortality is decreasing in Europe. However, time trends in the USA and Canada remain uncertain because the most recent analyses of PE-related mortality were published in the early 2000s. Methods For this retrospective epidemiological study, we accessed medically certified vital registration data from the WHO Mortality Database (USA and Canada, 2000-17) and the Multiple Cause of Death database produced by the Division of Vital Statistics of the US Centers for Disease Control and Prevention (CDC; US, 2000-18). We investigated contemporary time trends in PE-related mortality in the USA and Canada and the prevalence of conditions contributing to PE-related mortality reported on the death certificates. We also estimated PE-related mortality by age group and sex. A subgroup analysis by race was performed for the USA. Findings In the USA, the age-standardised annual mortality rate (PE as the underlying cause) decreased from 6•0 deaths per 100 000 population (95% CI 5•9-6•1) in 2000 to 4•4 deaths per 100 000 population (4•3-4•5) in 2006. Thereafter, it continued to decrease to 4•1 deaths per 100 000 population (4•0-4•2) in women in 2017 and plateaued at 4•5 deaths per 100 000 population (4•4-4•7) in men in 2017. Among adults aged 25-64 years, it increased after 2006. The median age at death from PE decreased from 73 years to 68 years (2000-18). The prevalence of cancer, respiratory diseases, and infections as a contributing cause of PE-related death increased in all age categories from 2000 to 2018. The annual age-standardised PE-related mortality was consistently higher by up to 50% in Black individuals than in White individuals; these rates were approximately 50% higher in White individuals than in those of other races. In Canada, the annual age-standardised mortality rate from PE as the underlying cause of death decreased from 4•7 deaths per 100 000 population (4•4-5•0) in 2000 to 2•6 deaths per 100 000 population (2•4-2•8) in 2017; this decline slowed after 2006 across age groups and sexes. Interpretation After 2006, the initially decreasing PE-related mortality rates in North America progressively reached a plateau in Canada, while a rebound increase was observed among young and middle-aged adults in the USA. These findings parallel recent upward trends in mortality from other cardiovascular diseases and might reflect increasing inequalities in the exposure to risk factors and access to health care.

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Section: Discussionmentioning

confidence: 99%

Age-sex specific pulmonary embolism-related mortality in the USA and Canada, 2000–18: an analysis of the WHO Mortality Database and of the CDC Multiple Cause of Death database

Barco

Valerio

Ageno

et al. 2021

The Lancet Respiratory Medicine

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146

105

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“…In spite of 20% of women with cardiac arrest, 94% of women survived (95%CI 86-98%). This figure contrasts with a 57% survival among 67 pregnant women with PE treated with thrombolysis from a German administrative cohort [2]. Likely, the true survival lies between these numbers, which are affected by reporting bias and misclassification, respectively.…”

Section: Systemic Thrombolysismentioning

confidence: 64%

“…Its most severe form, high-risk ("massive") PE, causes hemodynamic instability through an acute extensive pulmonary arterial obstruction, and is associated with a 15-50% in-hospital mortality in non-pregnant populations [1]. During pregnancy, up to 7% of PEs may present with such hemodynamic instability [2], and high-risk pregnancy-associated PE (PA-PE) is responsible for about 10-15% of all maternal deaths in Europe and North America [3] [2].…”

Section: Introductionmentioning

confidence: 99%

Management of high-risk pulmonary embolism in pregnancy

Blondon¹,

Tejada

Glauser³

et al. 2021

Thrombosis Research

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Pregnancy-associated high-risk pulmonary embolism (PE) is among the most frequent causes of maternal mortality in the Western world, by causing hemodynamic instability and circulatory failure through a large thrombotic pulmonary obstruction. The very challenging management of these dramatic situations comprises the need to quickly select a therapy of pulmonary reperfusion or hemodynamic replacement, while taking into account both maternal and fetal risks. In this review, we discuss the role of risk stratification in pregnancyassociated PE and the available evidence to support the use of thrombolysis, catheter-directed thrombectomy/ thrombolysis, surgical embolectomy and extracorporeal membrane oxygenation. Despite the lack of comparative studies and solid evidence, most reported cases of high-risk pregnancy-associated PE have been treated with thrombolysis, with high maternal and fetal survivals, and thrombolysis is suggested by guidelines in lifethreatening PE. For women in the peripartum and early post-partum period, non-fibrinolytic treatments may be preferred as a first-line treatment, if available, because of the particularly high bleeding risk. In all cases, pregnancy-associated high-risk PE requires a multidisciplinary approach involving PE response teams and obstetricians.

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“… 15 , 16 Particularly vulnerable are women during pregnancy and postpartum and obese patients, for whom high‐quality evidence supporting clinical decisions is not available. 17 , 18 , 19 , 20…”

Section: Introductionmentioning

confidence: 99%

“…Despite these reassuring trends, PE associated with hemodynamic instability portends unacceptably high rates of in‐hospital or early death 15,16 . Particularly vulnerable are women during pregnancy and postpartum and obese patients, for whom high‐quality evidence supporting clinical decisions is not available 17‐20 …”

Section: Introductionmentioning

confidence: 99%

Global reporting of pulmonary embolism–related deaths in the World Health Organization mortality database: Vital registration data from 123 countries

Valerio

Gallo

Turatti

et al. 2021

Research and Practice in Thrombosis and Haemostasis

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Introduction Pulmonary embolism (PE) has not been accounted for as a cause of death contributing to cause‐specific mortality in global reports. Methods We analyzed global PE‐related mortality by focusing on the latest year available for each member state in the World Health Organization (WHO) mortality database, which provides age‐sex–specific aggregated mortality data transmitted by national authorities for each underlying cause of death. PE‐related deaths were defined by International Classification of Diseases, Tenth Revision codes for acute PE or nonfatal manifestations of venous thromboembolism (VTE). The 2001 WHO standard population served for standardization. Results We obtained data from 123 countries covering a total population of 2 602 561 422. Overall, 50 (40.6%) were European, 39 (31.7%) American, 13 (10.6%) Eastern Mediterranean, 13 (10.6%) Western Pacific, 3 (2.4%) Southeast Asian, and 2 (1.6%) African. Of 116 countries classifiable according to population income, 57 (49.1%) were high income, 42 (36.2%) upper‐middle income, 14 (12.1%) lower‐middle income, and 3 (2.6%) low income. A total of 18 726 382 deaths were recorded, of which 86 930 (0.46%) were attributed to PE. PE‐related mortality rate increased with age in most countries. The reporting of PE‐related deaths was heterogeneous, with an age‐standardized mortality rate ranging from 0 to 24 deaths per 100 000 population‐years. Income status only partially explained this heterogeneity. Conclusions Reporting of PE‐related mortality in official national vital registration was characterized by extreme heterogeneity across countries. These findings mandate enhanced efforts toward systematic and uniform coverage of PE‐related mortality and provides a case for full recognition of PE and VTE as a primary cause of death.

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Fatality rates and use of systemic thrombolysis in pregnant women with pulmonary embolism

Cited by 20 publications

References 26 publications

Age-sex specific pulmonary embolism-related mortality in the USA and Canada, 2000–18: an analysis of the WHO Mortality Database and of the CDC Multiple Cause of Death database

Age-sex specific pulmonary embolism-related mortality in the USA and Canada, 2000–18: an analysis of the WHO Mortality Database and of the CDC Multiple Cause of Death database

Management of high-risk pulmonary embolism in pregnancy

Global reporting of pulmonary embolism–related deaths in the World Health Organization mortality database: Vital registration data from 123 countries

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