Long term prognosis of acute pulmonary embolism


      • Acute pulmonary embolism attributable to a neoplasia associates with the worst prognosis.
      • Approximately 80% of patients with acute PE attributable to a neoplasia die within 1-year.
      • Idiopathic PE portends higher death risk than PE secondary to a non-neoplastic condition.
      • Acute idiopathic PE should be looked at as a worrisome clinical entity.



      Acute pulmonary embolism (PE) can be fatal if left untreated. Long-term prognosis of acute PE in the 21st century has not been fully reported. We aimed to determine the long-term prognosis of patients hospitalized with acute PE and compare survivalof patients with idiopathic and secondary PE.

      Materials and methods

      We retrospectively analysed a cohort of hospitalized patients with acute PE between 2006 and 2013. Exclusion criteria:<18 years, venous embolism of non-pulmonary veins, chronic thromboembolic pulmonary hypertension, and presumptive diagnosis without image confirmation. Only patients with a first PE episode were included. End-point: all-cause mortality. Patients were compared according to PE aetiology: idiopathic, secondary to neoplastic conditions and secondary to non-neoplastic conditions. A Cox-regression analysis was used to study the prognostic impact of PE aetiology. RESULTS: We studied 872 hospitalized acute PE patients. Median age 70 years, 56.9% were women. PE was idiopathic in 376 (43.1%), secondary to a neoplastic condition in 284 (32.6%) and secondary to a condition other than neoplasia in 212 (24.3%). Patients were followed for a median 25 months period and 508 (58.3%) died. Patients with PE attributed to a neoplastic condition had the worst survival. Patients with idiopathic PE had a multivariate-adjusted HR of mortality of 1.46 (1.08–1.99) during the over 2-year follow-up period when compared to those with acute PE attributed to a non-neoplastic condition.


      Patients with idiopathic acute PE have an almost 50% higher death risk in a median 2-year follow-up period than those with acute PE secondary to a condition other than neoplasia.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Konstantinides S.V.
        • Torbicki A.
        • Agnelli G.
        • Danchin N.
        • Fitzmaurice D.
        • Galie N.
        • et al.
        ESC guidelines on the diagnosis and management of acute pulmonary embolism.
        Eur Heart J. 2014; 35 (69a-69k): 3033-3069
        • Goldhaber S.Z.
        • Bounameaux H.
        Pulmonary embolism and deep vein thrombosis.
        Lancet. 2012; 379: 1835-1846
        • Wiener R.S.
        • Schwartz L.M.
        • Woloshin S.
        Time trends in pulmonary embolism in the United States: evidence of overdiagnosis.
        Arch Intern Med. 2011; 171: 831-837
        • Huang W.
        • Goldberg R.J.
        • Anderson F.A.
        • Kiefe C.I.
        • Spencer F.A.
        Secular trends in occurrence of acute venous thromboembolism: the Worcester VTE Study (1985-2009).
        Am J Med. 2014; 127: 829-39 e5
        • Turetz M.
        • Sideris A.T.
        • Friedman O.A.
        • Triphathi N.
        • Horowitz J.M.
        Epidemiology, pathophysiology, and natural history of pulmonary embolism.
        Semin Interv Radiol. 2018; 35: 92-98
        • Alotaibi G.
        • Wu C.
        • Senthilselvan A.
        • McMurtry M.S.
        Short- and long-term mortality after pulmonary embolism in patients with and without cancer.
        Vasc Med. 2018; 23: 261-266
        • Kearon C.
        Natural history of venous thromboembolism.
        Circ. 2003; 107: I22-I30
        • Gao S.
        • Escalante C.
        Venous thromboembolism and malignancy.
        Expert Rev Anticancer Ther. 2004; 4: 303-320
        • Lyman G.H.
        Venous thromboembolism in the patient with cancer: focus on burden of disease and benefits of thromboprophylaxis.
        Cancer. 2011; 117: 1334-1349
        • Lyman G.H.
        • Khorana A.A.
        • Falanga A.
        • Clarke-Pearson D.
        • Flowers C.
        • Jahanzeb M.
        • et al.
        American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer.
        J Clin Oncol. 2007; 25: 5490-5505
        • Gjonbrataj E.
        • Kim J.N.
        • Gjonbrataj J.
        • Jung H.I.
        • Kim H.J.
        • Choi W.I.
        Risk factors associated with provoked pulmonary embolism.
        Korean J Intern Med. 2017; 32: 95-101
        • Miniati M.
        • Cenci C.
        • Monti S.
        • Poli D.
        Clinical presentation of acute pulmonary embolism: survey of 800 cases.
        PLoS One. 2012; 7e30891
        • Pollack C.V.
        • Schreiber D.
        • Goldhaber S.Z.
        • Slattery D.
        • Fanikos J.
        • O'Neil B.J.
        • et al.
        Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (multicenter emergency medicine pulmonary embolism in the real world registry).
        J Am Coll Cardiol. 2011; 57: 700-706
        • Stoeva N.
        • Kirova G.
        • Staneva M.
        • Lekova D.
        • Penev A.
        • Bakalova R.
        Recognition of unprovoked (idiopathic) pulmonary embolism-prospective observational study.
        Respir Med. 2018; 135: 57-61
        • Aleman C.
        • Sanchez L.
        • Alegre J.
        • Ruiz E.
        • Vazquez A.
        • Soriano T.
        • et al.
        Differentiating between malignant and idiopathic pleural effusions: the value of diagnostic procedures.
        QJM. 2007; 100: 351-359
        • Venekamp L.N.
        • Velkeniers B.
        • Noppen M.
        Does 'idiopathic pleuritis' exist? Natural history of non-specific pleuritis diagnosed after thoracoscopy.
        Respir. 2005; 72: 74-78
        • Gussoni G.
        • Frasson S.
        • La Regina M.
        • Di Micco P.
        • Monreal M.
        • Investigators R.
        Three-month mortality rate and clinical predictors in patients with venous thromboembolism and cancer. Findings from the RIETE registry.
        Thromb Res. 2013; 131: 24-30
        • Lehmann R.
        • Luxembourg B.
        • Miesbach W.
        • Suess C.
        • Leus M.
        • Lindhoff-Last E.
        • et al.
        Idiopathic (unexplained) pulmonary embolism is associated with an impaired prognosis compared to other entities of pulmonary embolism.
        Blood Coagul Fibrinolysis. 2010; 21: 70-76
        • Baglin T.
        • Gray E.
        • Greaves M.
        • Hunt B.J.
        • Keeling D.
        • Machin S.
        • et al.
        Clinical guidelines for testing for heritable thrombophilia.
        Br J Haematol. 2010; 149: 209-220
        • Middeldorp S.
        • van Hylckama Vlieg A.
        Does thrombophilia testing help in the clinical management of patients?.
        Br J Haematol. 2008; 143: 321-335
        • Nicolaides A.N.
        • Fareed J.
        • Kakkar A.K.
        • Comerota A.J.
        • Goldhaber S.Z.
        • Hull R.
        • et al.
        Prevention and treatment of venous thromboembolism--international consensus statement.
        Int Angiol. 2013; 32: 111-260
        • Coppens M.
        • Reijnders J.H.
        • Middeldorp S.
        • Doggen C.J.
        • Rosendaal F.R.
        Testing for inherited thrombophilia does not reduce the recurrence of venous thrombosis.
        J Thromb Haemost. 2008; 6: 1474-1477
        • Christiansen S.C.
        • Cannegieter S.C.
        • Koster T.
        • Vandenbroucke J.P.
        • Rosendaal F.R.
        Thrombophilia, clinical factors, and recurrent venous thrombotic events.
        JAMA. 2005; 293: 2352-2361
        • Zhu T.
        • Martinez I.
        • Emmerich J.
        Venous thromboembolism: risk factors for recurrence.
        Arterioscler Thromb Vasc Biol. 2009; 29: 298-310
        • Kearon C.
        • Akl E.A.
        • Ornelas J.
        • Blaivas A.
        • Jimenez D.
        • Bounameaux H.
        • et al.
        Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report.
        Chest. 2016; 149: 315-352
        • Baglin T.
        • Douketis J.
        • Tosetto A.
        • Marcucci M.
        • Cushman M.
        • Kyrle P.
        • et al.
        Does the clinical presentation and extent of venous thrombosis predict likelihood and type of recurrence? A patient-level meta-analysis.
        J Thromb Haemost. 2010; 8: 2436-2442
        • Boutitie F.
        • Pinede L.
        • Schulman S.
        • Agnelli G.
        • Raskob G.
        • Julian J.
        • et al.
        Influence of preceding length of anticoagulant treatment and initial presentation of venous thromboembolism on risk of recurrence after stopping treatment: analysis of individual participants' data from seven trials.
        BMJ. 2011; 342: d3036
        • Couturaud F.
        • Sanchez O.
        • Pernod G.
        • Mismetti P.
        • Jego P.
        • Duhamel E.
        • et al.
        Six months vs extended Oral anticoagulation after a first episode of pulmonary embolism: the PADIS-PE randomized clinical trial.
        JAMA. 2015; 314: 31-40
        • Kovacs M.J.
        • Kahn S.R.
        • Wells P.S.
        • Anderson D.A.
        • Chagnon I.
        • G L.E.G.
        • et al.
        Patients with a first symptomatic unprovoked deep vein thrombosis are at higher risk of recurrent venous thromboembolism than patients with a first unprovoked pulmonary embolism.
        J Thromb Haemost. 2010; 8: 1926-1932
        • Prandoni P.
        • Bilora F.
        • Marchiori A.
        • Bernardi E.
        • Petrobelli F.
        • Lensing A.W.
        • et al.
        An association between atherosclerosis and venous thrombosis.
        N Engl J Med. 2003; 348: 1435-1441