Original article| Volume 84, P18-23, February 2021

Download started.


The effect of COPD on the incidence and mortality of hospitalized patients with pulmonary embolism: A nationwide population-based study (2016-2018)

Published:November 26, 2020DOI:


      • Adjusted incidence of hospitalizations for PE was higher in COPD patients.
      • In hospital mortality (IHM) was significantly associated with suffering COPD.
      • IHM predictors included age, comorbidity, atrial fibrillation and oxygen dependence
      • Obesity was associated with lower IHM in COPD patients hospitalized with PE.



      To examine the incidence, clinical characteristics, and in-hospital outcomes of pulmonary embolism (PE) among hospitalized patients with or without chronic obstructive pulmonary disease (COPD) in Spain, and to identify predictors of in-hospital-mortality (IHM) after PE among patients with and without COPD.


      We included all patients aged ≥ 40 years who were hospitalised for PE between 2016 and 2018. Data were collected from the Spanish National Hospital Discharge Database.


      We identified 47,190 hospitalizations for PE during the study period, 7.49% with COPD. Adjusted incidence of PE was higher in COPD patients than in those without COPD (IRR 1.16; 95%CI 1.13-1.19). Crude IHM was significantly higher in PE hospitalized patients with COPD than in those without COPD (9.86% vs 3.59%; p<0.001). Predictor factors of IHM in COPD patients with PE included older age, higher Charlson comorbidity index, atrial fibrillation, massive PE and dependence on oxygen prior to hospital admission. However, obesity was associated with lower IHM. For PE hospitalized patients, suffering COPD increased the probability of dying in the hospital (adjusted OR 2.84; 95%CI 2.27-3.55).


      Our results revealed that incidence of PE was higher in COPD patients than in those without COPD. Furthermore, COPD was a risk factor for IHM after PE.



      BMI (body mass index), CCI (Charlson comorbidity index), CI (confidence intervals), COPD (chronic obstructive pulmonary disease), DRG (diagnosis-related groups), ICD-10 (international classification of diseases-10th revision), IHM (in-hospital-mortality), IRR (incidence rate ratios), LOHS (length of hospital stay), OR (odds ratio), PE (pulmonary embolism), PSM (propensity score matching), SNHDD (Spanish national hospital discharge database)
      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


        • Soriano JB
        • Alfageme I
        • Miravitlles M
        • de Lucas P
        • Soler-Cataluña JJ
        • García-Río F
        • et al.
        Prevalence and determinants of COPD in Spain: EPISCAN II.
        Arch Bronconeumol. 2020; (S0300-2896(20)30259-3)
        • Mathers CD
        • Loncar D
        Projections of global mortality and burden of disease from 2002 to 2030.
        PLoS Med. 2006; 3: e442
      1. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2020 report. [accessed: 15 May 2020].

        • Poulsen SH
        • Noer I
        • Møller JE
        • Knudsen TE
        • Frandsen JL
        Clinical outcome of patients with suspected pulmonary embolism. A follow-up study of 588 consecutive patients.
        J Intern Med. 2001; 250: 137-143
        • Mejza F
        • Lamprecht B
        • Niżankowska-Mogilnicka E
        • Undas A
        Arterial and venous thromboembolism in chronic obstructive pulmonary disease: from pathogenic mechanisms to prevention and treatment.
        Pneumonol Alergol Pol. 2015; 83: 485-494
        • Cao YQ
        • Dong LX
        • Cao J
        Pulmonary embolism in patients with acute exacerbation of chronic obstructive pulmonary disease.
        Chin Med J (Engl). 2018; 13: 1732-1737
        • Chen WJ
        • Lin CC
        • Lin CY
        • Chang YJ
        • Sung FC
        • Kao CH
        • et al.
        Pulmonary embolism in chronic obstructive pulmonary disease: a population-based cohort study.
        COPD. 2014; 11: 438-443
        • Pourmand A
        • Robinson H
        • Mazer-Amirshahi M
        • Pines JM
        Pulmonary embolism among patients with acute exacerbation of chronic obstructive pulmonary disease: implications for emergency medicine.
        J Emerg Med. 2018; 55: 339-346
        • Hassen MF
        • Tilouche N
        • Jaoued O
        • Elatrous S
        Incidence and impact of pulmonary embolism during severe COPD exacerbation.
        Respir Care. 2019; 64: 1531-1536
        • Dentali F
        • Pomero F
        • Micco PD
        • La Regina M
        • Landini F
        • Mumoli N
        • et al.
        Prevalence and risk factors for pulmonary embolism in patients with suspected acute exacerbation of COPD: a multi-center study.
        Eur J Intern Med. 2020; 80: 54-59
        • Piazza G
        • Goldhaber SZ
        • Kroll A
        • Goldberg RJ
        • Emery C
        • Spencer FA
        Venous thromboembolism in patients with chronic obstructive pulmonary disease.
        Am J Med. 2012; 125: 1010-1018
        • Bertoletti L
        • Quenet S
        • Mismetti P
        • Hernández L
        • Martín-Villasclaras JJ
        • Tolosa C
        • et al.
        Clinical presentation and outcome of venous thromboembolism in COPD.
        Eur Respir J. 2012; 39: 862-868
        • Bahloul M
        • Chaari A
        • Tounsi A
        • Baccouche N
        • Abid H
        • Chtara K
        • et al.
        Incidence and impact outcome of pulmonary embolism in critically ill patients with severe exacerbation of chronic obstructive pulmonary diseases.
        Clin Respir J. 2015; 9: 270-277
      2. Ministry of Health. Spanish National Hospital Discharge Database (Conjunto Minimo Basico de Datos). [accessed 15 April 2020].

        • Smith SB
        • Geske JB
        • Kathuria P
        • Cuttica M
        • Schimmel DR
        • Courtney DM
        • et al.
        Analysis of national trends in admissions for pulmonary embolism.
        Chest. 2016; 150: 35-45
        • Quan H
        • Sundararajan V
        • Halfon P
        • Fong A
        • Burnand B
        • Luthi JC
        • et al.
        Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
        Med Care. 2005; 43: 1130-1139
      3. Instituto Nacional de la Salud. Ministerio de Sanidad y Consumo. CMBD Insalud. Análisis de los GRDs. Año 2000. [accessed 15 May 2020].

        • Austin PC.
        An introduction to propensity score methods for reducing the effects of confounding in observational studies.
        Multivariate Behav Res. 2011; 46: 399-424
        • D'Agostino Jr, RB
        Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group.
        Stat Med. 1998; 17: 2265-2281
      4. Instituto Nacional de Estadística. Encuesta Nacional de Salud 2017 [Spanish National Health Survey 2017]. [accessed 20 January 2020].

        • Instituto Nacional de Estadística
        Population estimates.
        National Stadistical Institute, 2016 ( [accessed 8 January 2020])
        • Curkendall SM
        • DeLuise C
        • Jones JK
        • Lanes S
        • Stang MR
        • Goehring Jr, E
        • et al.
        Cardiovascular disease in patients with chronic obstructive pulmonary disease, Saskatchewan Canada cardiovascular disease in COPD patients.
        Ann Epidemiol. 2006; 16: 63-70
        • Schneider C
        • Bothner U
        • Jick SS
        • Meier CR
        Chronic obstructive pulmonary disease and the risk of cardiovascular diseases.
        Eur J Epidemiol. 2010; 25: 253-260
        • Tichelaar YIGV
        • Kluin-Nelemans HJC
        • Meijer K
        Infections and inflammatory diseases as risk factors for venous thrombosis. A systematic review.
        Thromb Haemost. 2012; 107: 827-837
        • Børvik T
        • Brækkan SK
        • Enga K
        • Schirmer H
        • Brodin EE
        • Melbye H
        • et al.
        COPD and risk of venous thromboembolism and mortality in a general population.
        Eur Respir J. 2016; 47: 473-481
        • Akpinar EE
        • Hoşgün D
        • Akpinar S
        • Ataç GK
        • Doğanay B
        • Gülhan M
        Incidence of pulmonary embolism during COPD exacerbation.
        J Bras Pneumol. 2014; 40: 38-45
        • Rizkallah J
        • Man SFP
        • Sin DD
        Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis.
        Chest. 2009; 135: 786-793
        • Kim V
        • Goel N
        • Gangar J
        • Zhao H
        • Ciccolella DE
        • Silverman EK
        • et al.
        Risk factors for venous thromboembolism in chronic obstructive pulmonary disease.
        Chronic Obstr Pulm Dis. 2014; 1: 239-249
        • Aleva FE
        • Voets LWLM
        • Simons SO
        • Mast Q
        • van der Ven AJAM
        • Heijdra YF
        Prevalence and localization of pulmonary embolism in unexplained acute exacerbations of COPD: a systematic review and meta-analysis.
        Chest. 2017; 151: 544-554
        • Bauer PR.
        Obesity paradox in pulmonary embolism: myth or reality?.
        Mayo Clin Proc. 2019; 94: 1925-1927
        • Stein PD
        • Matta F
        • Goldman J
        Obesity and pulmonary embolism: the mounting evidence of risk and the mortality paradox.
        Thromb Res. 2011; 128: 518-523
        • Fernández C
        • Jiménez D
        • De Miguel J
        • Martí D
        • Díaz G
        • Sueiro A
        [Chronic obstructive pulmonary disease in patients with acute symptomatic pulmonary embolism].
        Arch Bronconeumol. 2009; 45: 286-290
        • Motte S
        • Mélot C
        • Pierdomenico LD
        • Martins D
        • Leclercq P
        • Pirson M
        Predictors of costs from the hospital perspective of primary pulmonary embolism.
        Eur Respir J. 2016; 47: 203-211
        • Monreal M
        • Sanchez Muñoz-Torrero JF
        • Naraine VS
        • Jiménez D
        • Soler S
        • Rabuñal R
        • et al.
        Pulmonary embolism in patients with chronic obstructive pulmonary disease or congestive heart failure.
        Am J Med. 2006; 119: 851-858
        • Hopkins N
        • McLoughlin P.
        The structural basis of pulmonary hypertension in chronic lung disease: remodelling, rarefaction or angiogenesis?.
        J Anat. 2002; 201: 335-348
        • Ng ACC
        • Chow V
        • Yong ASC
        • Chung T
        • Kritharides L
        Prognostic impact of the Charlson comorbidity index on mortality following acute pulmonary embolism.
        Respiration. 2013; 85: 408-416
        • Polo Friz H
        • Corno V
        • Orenti A
        • Buzzini C
        • Crivellari C
        • Petri F
        • et al.
        Comorbidity assessment as predictor of short and long-term mortality in elderly patients with hemodynamically stable acute pulmonary embolism.
        J Thromb Thrombolysis. 2017; 44: 316-323
        • Gupta R
        • Ammari Z
        • Dasa O
        • Ruzieh M
        • Burlen JJ
        • Shunnar KM
        • et al.
        Long-term mortality after massive, submassive, and low-risk pulmonary embolism.
        Vasc Med. 2020; 25: 141-149
        • Ptaszynska-Kopczynska K
        • Kiluk I
        • Sobkowicz B
        Atrial fibrillation in patients with acute pulmonary embolism: clinical significance and impact on prognosis.
        Biomed Res Int. 2019; 20197846291
        • Keller K
        • Hobohm L
        • Münzel T
        • Ostad MA
        • Espinola-Klein C
        • Lavie CJ
        • et al.
        Survival benefit of obese patients with pulmonary embolism.
        Mayo Clin Proc. 2019; 94: 1960-1973