Central embolic localization in acute pulmonary embolism: Prognostic marker or target for intervention?

In patients with acute pulmonary embolism (PE), computed tomography pulmonary angiography (CTPA) enables both diagnosis and prognosis. This analysis of symptomatic acute PE patients aims to describe clinical features, management, and short-term outcomes by embolic localization, and to assess the prognostic value of central emboli.

COPE (COntemporary management of acute Pulmonary Embolism) is a nationwide Italian cohort study run in Internal Medicine, Cardiology and Emergency Departments including 5,213 patients with symptomatic, objectively confirmed acute PE. Patients with data on embolic localization available were included in this analysis.

Overall, 4,415 patients were included; 61.5% with central, 33.2% with segmental and 5.3% with subsegmental embolic localization. Central PE was found in 85.4% and in 83.7% of patients at high or at intermediate-high risk according to ESC 2019. Central embolic localization was not associated with all-cause death at 30 days, but was an independent predictor of PE-related death (1.7% vs 0.6%, HR 2.11, 95% CI 1.08-4.11) and of death or clinical deterioration (7.2% vs 5.7%, HR 1.37, 95% CI 1.05-1.79) compared to segmental/subsegmental localization. Among intermediate-risk patients according to the ESC classification, central PE was able to identify those at higher risk of PE-related death (1.6% vs 0.4%, HR 4.69, 95% CI 1.67-13.22).

In patients with acute PE, the main determinant of a poor outcome is hemodynamic compromise. Central localization of emboli is not associated to all-cause-death, but could be used to identify intermediate-low risk patients at increased risk for PE-related death.