Temporal trends in outpatient management of incident pulmonary embolism and associated mortality

Trends in Discharge Rates for Acute Pulmonary Embolism in U.S. Emergency Departments

BACKGROUND

Outpatient management of select patients with low-risk acute pulmonary embolism (PE) has been proven to be safe and effective, yet recent evidence suggests that patients are still managed with hospitalization. Few studies have assessed contemporary real-world trends in discharge rates from U.S. emergency departments (EDs) for acute PE.

OBJECTIVE

To evaluate whether the proportion of discharges from EDs for acute PE changed between 2012 and 2020 and which baseline characteristics are associated with ED discharge.

DESIGN

Serial cross-sectional analysis.

SETTING

U.S. EDs participating in the National Hospital Ambulatory Medical Care Survey.

PATIENTS

Patients with ED visits for acute PE between 2012 and 2020.

MEASUREMENTS

National trends in the proportion of discharges for acute PE and factors associated with ED discharge.

RESULTS

Between 2012 and 2020, there were approximately 1 635 300 visits for acute PE. Overall, ED discharge rates remained constant over time, with rates of 38.2% (95% CI, 17.9% to 64.0%) between 2012 and 2014 and 33.4% (CI, 21.0% to 49.0%) between 2018 and 2020 (adjusted risk ratio, 1.01 per year [CI, 0.89 to 1.14]). No baseline characteristics, including established risk stratification scores, were predictive of an increased likelihood of ED discharge; however, patients at teaching hospitals and those with private insurance were more likely to receive oral anticoagulation at discharge. Only 35.9% (CI, 23.9% to 50.0%) of patients who were considered low-risk according to their Pulmonary Embolism Severity Index (PESI) class, 33.1% (CI, 21.6% to 47.0%) according to simplified PESI score, and 34.8% (CI, 23.3% to 48.0%) according to hemodynamic stability were discharged from the ED setting.

LIMITATIONS

Cross-sectional survey design and inability to adjudicate diagnoses.

CONCLUSION

In a representative nationwide sample, rates of discharge from the ED for acute PE appear to have remained constant between 2012 and 2020. Only one third of low-risk patients were discharged for outpatient management, and rates seem to have stabilized. Outpatient management of low-risk acute PE may still be largely underutilized in the United States.

PRIMARY FUNDING SOURCE

None.

Identification of Low-risk Patients With Acute Symptomatic Pulmonary Embolism

BACKGROUND

Identification of patients with acute symptomatic pulmonary embolism (PE) who are at low-risk for short-term complications to warrant outpatient care lacks clarity.

METHOD

In order to identify patients at low-risk for 30-day all-cause and PE-related mortality, we used a cohort of haemodynamically stable patients from the RIETE registry to compare the false-negative rate of four strategies: the simplified Pulmonary Embolism Severity Index (sPESI); a modified (i.e., heart rate cutoff of 100beats/min) sPESI; and a combination of the original and the modified sPESI with computed tomography (CT)-assessed right ventricle (RV)/left ventricle (LV) ratio.

RESULTS

Overall, 137 of 3117 patients with acute PE (4.4%) died during the first month. Of these, 41 (1.3%) died from PE, and 96 (3.1%) died from other causes. The proportion of patients categorized as having low-risk was highest with the sPESI and lowest with the combination of a modified sPESI and CT-assessed RV/LV ratio (32.5% versus 16.5%; P<0.001). However, among patients identified as low-risk, the 30-day mortality rate was lowest with the combination of a modified sPESI and CT-assessed RV/LV ratio and highest with the sPESI (0.4% versus 1.0%; P=0.03). The 30-day PE-related mortality rates for patients designated as low-risk by the sPESI, the modified sPESI, and the combination of the original and modified sPESI with CT-assessed RV/LV ratio were 0.7%, 0.4%, 0.7%, and 0.2%, respectively.

CONCLUSIONS

The combination of a negative modified sPESI with CT-assessed RV/LV ratio ≤1 identifies patients with acute PE who are at very low-risk for short-term mortality.

Temporal Trends in the Use of Computed Tomographic Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department : A Retrospective Analysis

BACKGROUND

Recently, validated clinical decision rules have been developed that avoid unnecessary use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED).

OBJECTIVE

To measure any resulting change in CTPA use for suspected PE.

DESIGN

Retrospective analysis.

SETTING

26 European EDs in 6 countries.

PATIENTS

Patients with CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019.

MEASUREMENTS

The primary end points were the CTPAs done for suspected PE in the ED and the number of PEs diagnosed in the ED each year adjusted to an annual census of 100 000 ED visits. Temporal trends were estimated using generalized linear mixed regression models.

RESULTS

8970 CTPAs were included (median age, 63 years; 56% female). Statistically significant temporal trends for more frequent use of CTPA (836 per 100 000 ED visits in 2015 vs. 1112 in 2019; P < 0.001), more diagnosed PEs (138 per 100 000 in 2015 vs. 164 in 2019; P = 0.028), a higher proportion of low-risk PEs (annual percent change [APC], 13.8% [95% CI, 2.6% to 30.1%]) with more ambulatory management (APC, 19.3% [CI, 4.1% to 45.1%]), and a lower proportion of intensive care unit admissions (APC, -8.9% [CI, -17.1% to -0.3%]) were observed.

LIMITATION

Data were limited to 7 days every 2 months.

CONCLUSION

Despite the recent validation of clinical decision rules to limit the use of CTPA, an increase in the CTPA rate along with more diagnosed PEs and especially low-risk PEs were instead observed.

PRIMARY FUNDING SOURCE

None specific for this study.

Epidemiology and prevention of venous thromboembolism

Venous thromboembolism, that consists of the interrelated conditions deep-vein thrombosis and pulmonary embolism, is an under-appreciated vascular disease. In Western regions, approximately 1 in 12 individuals will be diagnosed with venous thromboembolism in their lifetime. Rates of venous thromboembolism are lower in Asia, but data from other regions are sparse. Numerous risk factors for venous thromboembolism have been identified, which can be classified as acute or subacute triggers (provoking factors that increase the risk of venous thromboembolism) and basal or acquired risk factors (which can be modifiable or static). Approximately 20% of individuals who have a venous thromboembolism event die within 1 year (although often from the provoking condition), and complications are common among survivors. Fortunately, opportunities exist for primordial prevention (prevention of the development of underlying risk factors), primary prevention (management of risk factors among individuals at high risk of the condition) and secondary prevention (prevention of recurrent events) of venous thromboembolism. In this Review, we describe the epidemiology of venous thromboembolism, including the incidence, risk factors, outcomes and opportunities for prevention. Meaningful health disparities exist in both the incidence and outcomes of venous thromboembolism. We also discuss these disparities as well as opportunities to reduce them.

Analysis of contemporary mortality trends in pulmonary embolism, United States, 1999-2020

BACKGROUND

A contemporary and comprehensive examination of mortality trends in pulmonary embolism (PE) is needed for the United States (US), as previous studies were either based on preceding data or limited to specific demographic subgroups. We aimed to assess the trends in PE deaths by age, sex, race/ethnicity, and census region in the US from 1999 through 2020.

METHODS

We analyzed national mortality data using the CDC WONDER database. PE deaths were identified using the ICD-10 Code- I-26. Age adjusted mortality rates (AAMR) were abstracted by age, sex, race/ethnicity, and census region. Temporal trends were assessed using five-year moving averages and Joinpoint regression models. Annual percentage changes (APC) in AAMR were estimated using Monte Carlo Permutation, and 95 % confidence intervals using the Parametric Method.

RESULTS

Overall mortality trends have stabilized since 2009 (APC = 0.6; 95 % CI: -0.3, 1.6), as were trends among Non-Hispanic Whites (APC = 0.6; 95 % CI: -0.2, 1.4), Non-Hispanic Blacks (APC = 0.7; 95 % CI: -0.2, 1.6), and Hispanics (APC = 1.4; 95 % CI: -0.7, 3.6). AAMR declined by 1.7 % per year (95 % CI: -2.8, -0.7) among Asians/Pacific Islanders and by 1.4 % per year (95 % CI: -2.8, -0.0) among American Indians/Alaska Natives, from 1999 to 2020. Contemporary trends have increased among males (APC = 1.0; 95 % CI: 0.2, 1.9), persons below 65 years of age (APC = 18.6; 95 % CI: 18.6, 18.6; APC = 2.3; 95 % CI: 1.4, 3.1), and persons from the Northeastern (APC = 1.0; 95 % CI: 0.1, 2.0) and Western regions (APC = 1.6; 95 % CI: 0.7, 2.6).

CONCLUSIONS

The decline in PE mortality recorded from 1999 through the mid-2000s has not been sustained in the last decade-overall trends have stabilized since 2009. However, there were differences by age, sex, race/ethnicity, and the US census region, with some subgroups demonstrating stationary, increasing, or declining trends. Further studies should examine the drivers of differential trends in the US population to inform evidence-based and culturally competent public health intervention efforts.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Inpatient Versus Outpatient Acute Venous Thromboembolism Management: Trends and Postacute Healthcare Utilization From 2011 to 2018

Background Acute outpatient management of venous thromboembolism (VTE), which includes pulmonary embolism (PE) and deep vein thrombosis (DVT), is perceived to be as safe as inpatient management in some settings. How widely this strategy is used is not well documented. Methods and Results Using MarketScan administrative claims databases for years 2011 through 2018, we identified patients with International Classification of Diseases (ICD) codes indicating incident VTE and trends in the use of acute outpatient management. We also evaluated healthcare utilization and hospitalized bleeding events in the 6 months following the incident VTE event. A total of 200 346 patients with VTE were included, of whom 50% had evidence of PE. Acute outpatient management was used for 18% of those with PE and 57% of those with DVT only, and for both DVT and PE its use increased from 2011 to 2018. Outpatient management was less prevalent among patients with cancer, higher Charlson comorbidity index scores, and whose primary treatment was warfarin as compared with a direct oral anticoagulant. Healthcare utilization in the 6 months following the incident VTE event was generally lower among patients managed acutely as outpatients, regardless of initial presentation. Acute outpatient management was associated with lower hazard ratios of incident bleeding risk for both patients who initially presented with PE (0.71 [95% CI, 0.61, 0.82]) and DVT only (0.59 [95% CI, 0.54, 0.64]). Conclusions Outpatient management of VTE is increasing. In the present analysis, it was associated with lower subsequent healthcare utilization and fewer bleeding events. However, this may be because healthier patients were managed on an outpatient basis.

Comprehensive management of acute pulmonary embolism in primary care using telemedicine in the COVID-era

A healthy, active woman in her 70s reported intermittent exertional dyspnoea for 2 months, notable during frequent open-water swimming. Symptoms were similar to an episode of travel-provoked pulmonary embolism 3 years prior. She denied chest pain, cough, fever, extremity complaints and symptoms at rest. Due to the COVID-19 pandemic, her healthcare system was using secure telemedicine to evaluate non-critical complaints. During the initial video visit, she appeared well, conversing normally without laboured breathing. An elevated serum D-dimer prompted CT pulmonary angiography, which identified acute lobar pulmonary embolism. After haematology consultation and telephone conversation with the patient, her physician prescribed rivaroxaban. Her symptoms rapidly improved. She had an uneventful course and is continuing anticoagulation indefinitely. The pandemic has increased the application of telemedicine for acute care complaints. This case illustrates its safe and effective use for comprehensive management of acute pulmonary embolism in the primary care setting.

Sex-specific differences in the presentation, clinical course, and quality of life of patients with acute venous thromboembolism according to baseline risk factors. Insights from the PREFER in VTE

INTRODUCTION

Sex and the presence of specific provoking risk factors, along with age, influence the presentation and prognosis of venous thromboembolism (VTE). We investigated the presentation, course and quality of life in women and men with acute VTE classified according to their VTE provoking factors.

METHODS

PREFER in VTE is an international, non-interventional registry of patients with a first episode of acute symptomatic VTE. Baseline provoking factors were classified as follows: major transient, minor transient, active cancer, and none identifiable. The primary outcome was recurrent VTE. Quality of life and treatment satisfaction were secondary outcomes.

RESULTS

Of 3,455 patients with acute VTE, 1,623 (47%) were women. The mean age at the time of VTE was 61 (SD 18) in women, 60 (SD 15) in men. The distribution of provoking risk factors was similar between sexes, despite a tendency for higher frequency of minor and major transient risk factors in women, and cancer or unprovoked VTE in men. At 12-month follow-up, VTE recurrence was reported in 74 (6.5%) women and 80 (6.4%) men (absolute risk difference -0.1%, 95% CI -1.9%; +2.1%). In patients with unprovoked VTE, the VTE recurrence rate was 38/612 (6.2%) in women and 53/798 (6.6%) in men (absolute risk difference -0.4, 95% CI -3.0; +2.1%). Multivariable Cox regressions confirmed the absence of sex differences. Quality of life and treatment satisfaction scores one year after VTE were lower in women than in men irrespective of the provoking risk factors (p<0.001 for both scores).

CONCLUSIONS

Despite differences in the provoking risk factors for VTE, women and men had a similar rate VTE recurrence at one year. After acute VTE, women had lower quality of life and treatment satisfaction scores.

Trends in Mortality of Acute Pulmonary Embolism

Despite substantial advances in the diagnosis and management, pulmonary embolism (PE) continues to be a significant cause of mortality. In this article, we provide a concise overview of the evolution of worldwide mortality trends related to PE. Despite the data being derived mainly from observational studies, there is a clear trend toward decreasing mortality over time from PE. Whether this truly represents a treatment effect or is more related to increased diagnosis of small PEs is not fully clear. Modern approaches to PE management such as the PE response teams have the potential to further reduce the mortality from PE.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

CT Pulmonary Angiography for Risk Stratification of Patients with Nonmassive Acute Pulmonary Embolism

Purpose

To investigate the prognostic value of an integrative approach combining clinical variables and the Qanadli CT obstruction index (CTOI) in patients with nonmassive acute pulmonary embolism (PE).

Materials and Methods

This retrospective study included 705 consecutive patients (mean age, 63 years; range, 18-95 years) with proven PE. Clot burden was quantified using the CTOI, which reflects the ratio of fully or partially obstructed pulmonary arteries to normal arteries. Patients were subdivided into two groups according to the presence (group A) or absence (group B) of preexisting cardiopulmonary disease. Thirty-day and 3-month mortality was evaluated. CTOI thresholds of 20% and 40% were used to stratify patients regarding outcome (low, intermediate, and high risk). The predictive value of CTOI was assessed through logistic regression analysis.

Results

Analysis included 690 patients (mean age, 63.3 years ± 18 [standard deviation]) with complete follow-up data: 247 (36%) in group A and 443 (64%) in group B. The mean CTOI was 23% ± 19, 30-day mortality was 9.7%, and 3-month mortality was 11.6%. Three-month mortality was higher in group A than in group B (17.8% and 8.1%, respectively; P = .001). Within group B, CTOI predicted outcome and allowed stratification: significantly higher mortality with CTOI greater than 40% (P < .001) and lower mortality with CTOI less than 20% (P = .05). CTOI did not predict outcome in group A. Age was an independent mortality risk factor (P ≤ .04).

Conclusion

CTOI predicted outcome in this cohort of patients with PE and no cardiopulmonary disease, and it may provide a simple single-examination-based approach for risk stratification in this subset of patients.© RSNA, 2020See also the commentary by Kay and Abbara in this issue.

Predicting the occurrence of venous thromboembolism: construction and verification of risk warning model

Background

The onset of venous thromboembolism is insidious and the prognosis is poor. In this study, we aimed to construct a VTE risk warning model and testified its clinical application value.

Methods

Preliminary construction of the VTE risk warning model was carried out according to the independent risk warning indicators of VTE screened by Logistic regression analysis. The truncated value of screening VTE was obtained and the model was evaluated. ROC curve analysis was used to compare the test of Caprini risk assessment scale and VTE risk warning model. The cut-off value of the VTE risk warning model was used to evaluate the test effectiveness of the model for VTE patients with validation data set.

Results

The VTE risk warning model is p = e^x / (1+ e^x), x = − 4.840 + 2.557 • X₁₀₍₁₎ + 1.432 • X₁₄₍₁₎ + 2.977 • X₁₅₍₁₎ + 3.445 • X₁₈₍₁₎ + 1.086 • X₂₅₍₁₎ + 0.249 • X₃₄ + 0.282 • X₄₁. ROC curve results show that: AUC (95%CI), cutoff value, sensitivity, specificity, accuracy, Youden index, Caprini risk assessment scale is 0.596 (0.552, 0.638), 5, 26.07, 96.50, 61.3%, 0.226, VTE risk warning model is 0.960 (0.940, 0.976), 0.438, 92.61, 91.83, 92.2%, 0.844, respectively, with statistically significant differences (Z = 14.521, P < 0.0001). The accuracy and Youden index of VTE screening using VTE risk warning model were 81.8 and 62.5%, respectively.

Conclusions

VTE risk warning model had high accuracy in predicting VTE occurrence in hospitalized patients. Its test performance was better than Caprini risk assessment scale. It also had high test performance in external population.

Comprehensive Outpatient Management of Low-Risk Pulmonary Embolism: Can Primary Care Do This? A Narrative Review

INTRODUCTION

The evidence for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) is mounting. Guidance in identifying patients who are eligible for outpatient (ambulatory) care is available in the literature and society guidelines. Less is known about who can identify patients eligible for outpatient management and in what clinical practice settings.

OBJECTIVE

To answer the question, "Can primary care do this?" (provide comprehensive outpatient management of low-risk PE).

METHODS

We undertook a narrative review of the literature on the outpatient management of acute PE focusing on site of care. We searched the English-language literature in PubMed and Embase from January 1, 1950, through July 15, 2019.

RESULTS

We identified 26 eligible studies. We found no studies that evaluated comprehensive PE management in a primary care clinic or general practice setting. In 19 studies, the site-of-care decision making occurred in the Emergency Department (or after a short period of supplemental observation) and in 7 studies the decision occurred in a specialty clinic. We discuss the components of care involved in the diagnosis, outpatient eligibility assessment, treatment, and follow-up of ambulatory patients with acute PE.

DISCUSSION

We see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. Leading obstacles include lack of ready access to advanced pulmonary imaging and the time constraints of a busy outpatient clinic.

CONCLUSION

Until studies establish safe parameters of such a practice, the question "Can primary care do this?" must remain open.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Treatment and Outcomes of Acute Pulmonary Embolism and Deep Venous Thrombosis: The CVRN VTE Study

BACKGROUND

Few studies describe both inpatient and outpatient treatment and outcomes of patients with acute venous thromboembolism in the United States.

METHODS

A multi-institutional cohort of patients diagnosed with confirmed pulmonary embolism or deep venous thrombosis during the years 2004 through 2010 was established from 4 large, US-based integrated health care delivery systems. Computerized databases were accessed and medical records reviewed to collect information on patient demographics, clinical risk factors, initial antithrombotic treatment, and vital status. Multivariable Cox regression models were used to estimate the risk of death at 90 days.

RESULTS

The cohort comprised 5497 adults with acute venous thromboembolism. Pulmonary embolism was predominantly managed in the hospital setting (95.0%), while 54.5% of patients with lower extremity thrombosis were treated as outpatients. Anticoagulant treatment differed according to thromboembolism type: 2688 patients (92.8%) with pulmonary embolism and 1625 patients (86.9%) with lower extremity thrombosis were discharged on anticoagulants, compared with 286 patients (80.1%) with upper extremity thrombosis and 69 (54.8%) patients with other thrombosis. While 4.5% of patients died during the index episode, 15.4% died within 90 days. Pulmonary embolism was associated with a higher 90-day death risk than lower extremity thrombosis (adjusted hazard ratio 1.23; 95% confidence interval, 1.04-1.47), as was not being discharged on anticoagulants (adjusted hazard ratio 5.56; 95% confidence interval, 4.76-6.67).

CONCLUSIONS

In this multicenter, community-based study of patients with acute venous thromboembolism, anticoagulant treatment and outcomes varied by thromboembolism type. Although case fatality during the acute episode was relatively low, 15.4% of people with thromboembolism died within 90 days of the index diagnosis.