Prevalence and Predictors of Cardiogenic Shock in Intermediate-Risk Pulmonary Embolism: Insights From the FLASH Registry

doi:10.1016/j.jcin.2023.02.004

JACC: Cardiovascular Interventions

Volume 16, Issue 8, 24 April 2023, Pages 958-972

https://doi.org/10.1016/j.jcin.2023.02.004 Get rights and content

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Abstract

Background

Patients with acute pulmonary embolism (PE) and hypotension (high-risk PE) have high mortality. Cardiogenic shock can also occur in nonhypotensive or normotensive patients (intermediate-risk PE) but is less well characterized.

Objectives

The authors sought to evaluate the prevalence and predictors of normotensive shock in intermediate-risk PE.

Methods

Intermediate-risk PE patients in the FLASH (FlowTriever All-Comer Registry for Patient Safety and Hemodynamics) registry undergoing mechanical thrombectomy with the FlowTriever System (Inari Medical) were included. The prevalence of normotensive shock (systolic blood pressure ≥90 mm Hg but cardiac index ≤2.2 L/min/m²) was assessed. A composite shock score consisting of markers of right ventricular function and ischemia (elevated troponin, elevated B-type natriuretic peptide, moderately/severely reduced right ventricular function), central thrombus burden (saddle PE), potential additional embolization (concomitant deep vein thrombosis), and cardiovascular compensation (tachycardia) was prespecified and assessed for its ability to identify normotensive shock patients.

Results

Over one-third of intermediate-risk PE patients in FLASH (131/384, 34.1%) were in normotensive shock. The normotensive shock prevalence was 0% in patients with a composite shock score of 0 and 58.3% in those with a score of 6 (highest score). A score of 6 was a significant predictor of normotensive shock (odds ratio: 5.84; 95% CI: 2.00-17.04). Patients showed significant on-table improvements in hemodynamics post-thrombectomy, including normalization of the cardiac index in 30.5% of normotensive shock patients. Right ventricular size, function, dyspnea, and quality of life significantly improved at the 30-day follow-up.

Conclusions

Although hemodynamically stable, over one-third of intermediate-risk FLASH patients were in normotensive shock with a depressed cardiac index. A composite shock score effectively further risk stratified these patients. Mechanical thrombectomy improved hemodynamics and functional outcomes at the 30-day follow-up.

Central Illustration

Key Words

normotensive

pulmonary embolism

shock

thrombectomy

Abbreviations and Acronyms

BMI

body mass index

BNP

B-type natriuretic peptide

cardiac index

CTPA

computed tomography pulmonary angiography

DVT

deep vein thrombosis

ESC

European Society of Cardiology

left ventricular

MAE

major adverse event(s)

myocardial infarction

odds ratio

pulmonary artery

pulmonary embolism

right atrial

right ventricular

SBP

systolic blood pressure

sPESI

simplified pulmonary embolism severity index

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