January 6, 2021

Study Finds No Sex-Based Differences in Hospitalized Patients With Acute PE

January 6, 2021—Investigators analyzing contemporary patients admitted to a tertiary care center for acute pulmonary embolism (PE) found no sex disparities in PE management or outcomes. Pribish et al identified patients with acute PE admitted to Beth Israel Deaconess Medical Center between August 2012 and July 2018 using an internal billing claims database and a prospective registry of patients who received a PE response team (PERT) consult (after 2015). Retrospective chart review was used to evaluate patient demographics, comorbidities, clinical presentation, PE risk factors, PE severity, diagnostic studies, treatment modalities, and outcomes following a confirmed diagnosis of acute PE. Results of the analysis were presented at the 2020 American Heart Association Scientific Sessions and published online ahead of print in Vascular Medicine.

KEY FINDINGS

Dyspnea was a more common clinical presentation in women compared with men, but hemoptysis was less frequent. Frequency of asymptomatic presentation or presentation with symptoms such as chest pain, syncope, and cardiac arrest was not significantly different between sexes.
PE severity was similar between men and women, but women were more likely to have normal right ventricular (RV) size on surface echocardiography.
No significant sex-based differences were seen in any of the inpatient endpoints evaluated, including the need for intubation, vasopressor use, anticoagulant use, inferior vena cava (IVC) filter placement, and use of advanced therapies.
In unadjusted analyses, women were less likely to survive to discharge, but this difference was no longer apparent after adjustment.
Women had a lower rate of survival to discharge in the pre-PERT era, but there was no sex-based survival difference in the post-PERT era.

According to the investigators, previous studies have evaluated disparities between men and women with acute PE, but results have been conflicting. Few studies on sex differences in PE have assessed patient demographics and PE characteristics to adequately adjust for patient factors that could confound the evaluation of advanced therapies and outcomes, and there are no data related to the impact of PERTs on sex-specific outcomes.

The primary outcomes were clinical presentation, acuity of care, treatments received (anticoagulation, IVC filter placement, intravenous fibrinolysis, catheter-based therapies, surgical embolectomy, extracorporeal membrane oxygenation), and clinical outcomes (major bleeding, in-hospital survival, 90-day readmission, 90-day venous thromboembolism [VTE] recurrence). Patients were stratified by sex and differences in baseline characteristics, diagnostics, initial management, and outcomes were analyzed using Fisher’s exact or chi-square tests, and continuous variables were compared using Student’s t or Wilcoxon rank sum tests. P < .05 was considered significant.

The study population consisted of 1,081 (53.2%) women and 950 (46.8%) men. As compared with men, women were older (mean age, 63.8 ± 17.4 years vs 62.3 ± 15 years; P = .04) but were less likely to have a smoking history (43.1% vs 53.3%; P < .001), prior VTE (19.3% vs 24.2%; P < .01), myocardial infarction (6.6% vs 9.7%; P = .01), and liver disease (1.4% vs 3.5%; P < .01). However, they were more likely to have rheumatologic disorders (6.1% vs 3.3%; P < .01) and dementia (4% vs 1.7%; P < .01).

More women had dyspnea as a presenting symptom compared with men (59.8% vs 52%; P < .01), but hemoptysis was less frequent (1.9% vs 4%; P < .01). PE severity was similar between men and women (high risk, 4.9% vs 3.6%; submassive 43.9% vs 41.8%; low risk, 51.3% vs 54.6%; P = .19), but women were more likely to have normal right ventricular size on surface echocardiography (63.2% vs 54.8%).

Unadjusted analyses revealed that women were less likely to survive to discharge (92.4% vs 94.7% of men; P = .04), but after adjustment, this difference was no longer apparent. When survival to discharge was stratified by pre-PERT (August 2012-July 2015) and post-PERT era (August 2015-July 2018), the rate of survival to discharge was lower for women in the pre-PERT era (91.5% vs 95.0% of men; P = .045), but there was no sex-based survival difference in the post-PERT era (93.1% for women vs 94.5% for men; P = 0.33).

The investigators noted that although there were differences in comorbid conditions and presenting symptoms, no sex-based differences were found in PE severity, need for advanced therapies, or in-hospital or postdischarge outcomes.

ENDOVASCULAR TODAY ASKS

We asked authors Abby Pribish, MD, and Eric Secemsky, MD, from Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts:

What do your findings indicate about the effects of having a PERT in place?

Although our primary analysis did not focus on the interaction between PERTs and sex-based outcomes, in a secondary analysis, we did find that women had a lower rate of survival in the pre-PERT era, which was no longer apparent once our PERT was created. We feel this reflects the positive impact of PERT on the care of our hospitalized acute PE patients, where we now employ a more standardized, team-based approach to both the diagnosis and treatment of PE patients. In a previous study by our group, we found that after PERT implementation, there was an increase in use of PE risk stratification strategies, such as cardiac biomarkers and echocardiograms, and a decreased utilization of IVC filters and systemic thrombolysis, all of which we feel are important metrics of better care for acute PE patients. As an extension of this prior work and the current study, we do believe that PERT reduce disparities in health care by formalizing PE care, making it more algorithmic and evidence-based.

Will you make any adjustments in your practices based on the results of this study?

A few important themes emerged from this work that we think will impact our practice. First, unlike sex-differences in presentation for acute myocardial infarction, patients with acute PE tend to present similarly, with dyspnea remaining the predominant symptom. As such, a thorough review of symptoms is likely to capture both men and women presenting with concerns for PE. On the other hand, risk factors for PE notably varied between sexes. Women had more traditional risk factors, such as rheumatologic conditions and use of oral contraceptives and hormone replacement therapy, whereas men predominantly had atherosclerotic risk factors. These differences are important to note both in regard to the evaluation for PE, but also adjunctive therapies that may be additively beneficial such as statin therapy. Lastly, women were more likely to have a normal RV size on echocardiography, despite having similar PE severity and outcomes to men. Therefore, absence of RV enlargement may not be as prognostically important among women with acute PE.

What questions should future studies of sex-based differences in PE treatment and outcomes seek to address?

It has been shown that ethnicity can impact outcomes in cardiovascular disease. It would be interesting to examine how race and ethnicity interact with sex with regard to PE management and outcomes. In addition, our study did not account for transgender patients. Because this is a growing population (with some estimates that between 0.42%-0.6% of United States adults identify as transgender) and have a unique risk profile for PE (for example, higher rates of hormone therapy than the nontransgender patients), it is important to design large outcomes studies that specifically include the transgender population.

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