Malignancy-Associated Pulmonary Embolism: Mortality, Recurrence, and Bleeding Risks

TL;DR

Cancer patients with pulmonary embolism face higher late mortality than non-cancer patients, with age and biomarkers like NT-proBNP playing key roles in risk assessment.

Contribution

The study provides real-world evidence on outcomes of cancer-associated pulmonary embolism compared to non-cancer cases, highlighting late mortality differences and biomarker associations.

Findings

Cancer patients with PE had higher late mortality (38.7%) compared to non-cancer patients (3.3%).

NT-proBNP levels above 600 pg/mL were more common in cancer patients and associated with higher mortality risk.

DOAC use was less frequent in cancer patients compared to non-cancer patients.

Abstract

Background/Objectives: Pulmonary embolism (PE) remains a leading cause of morbidity and mortality, with outcomes influenced by patient demographics, comorbidities, and anticoagulation strategy. While vitamin K antagonists (VKA) have been standard therapy, direct oral anticoagulants (DOACs) are increasingly adopted, yet real-world data in cancer-associated and non-cancer populations are limited. This study aimed to compare demographics, clinical features, therapeutic strategies, and outcomes between oncologic patients with acute PE (experimental group) and non-cancer patients with PE (control group). Methods: We performed a multicentric retrospective cohort study of adults admitted with acute PE between January 2019 and December 2021. The cohort comprised 120 non-cancer and 106 cancer patients. Standard management was low-molecular-weight heparin with transition to (VKA) or (DOAC), when not contraindicated. Data on demographics, comorbidities, and laboratory biomarkers (including NT-proBNP, threshold 600 pg/mL) were analyzed. Primary outcomes were early (≤30 days) and late (31–365 days) all-cause mortality. Secondary outcomes included PE recurrence and bleeding events. Results: Among 226 PE patients (non-oncological n = 120; oncological n = 106), the cancer group was older (69.2 ± 12.6 vs. 62.6 ± 17.3 years; p = 0.001) with similar ECG findings and hemodynamic stability at presentation. NT-proBNP > 600 pg/mL was more frequent in cancer (37.7% vs. 23.3%; p = 0.018), whereas D-dimer > 5 mg/L was more common in non-cancer (74.2% vs. 55.7%; p = 0.003). DOAC use was lower in cancer patients (40.6% vs. 65.0%; p < 0.001). Early mortality was comparable (17.9% vs. 13.3%; p = 0.341), but late mortality was higher in the cancer patient subgroup (38.7% vs. 3.3%; p < 0.001). In multivariable analysis, belonging to the cancer subgroup was associated with NT-proBNP ≥ 600 (OR 2.08, 95% CI 1.08–4.01; p = 0.029) and older age (OR 1.025 per year, 95% CI 1.005–1.045; p = 0.016), and inversely associated with D-dimer > 5 mg/L (OR 0.35, 95% CI 0.19–0.64; p < 0.001). Conclusions: Prompt anticoagulation was associated with lower early mortality, while differences in late mortality appeared to be largely confounded by age and cancer status. NT-proBNP may serve as a useful risk-stratification biomarker, but confirmation in larger, prospective studies is required.