Trends in pulmonary embolism morbidity and mortality in Australia

doi:10.1016/j.thromres.2013.04.032

Thrombosis Research

Volume 132, Issue 1, July 2013, Pages 19-25

https://doi.org/10.1016/j.thromres.2013.04.032 Get rights and content

Abstract

Introduction

Pulmonary embolism (PE) is a common cause of morbidity and mortality. In this study, we investigated patterns of morbidity and mortality from PE in Australia.

Materials & Methods

Australian government databases were used to extract data on age and sex specific rates of mortality between 1997 and 2007, and hospital separations between 1998/9 and 2009/10 to examine changes over time and between age and sex groups.

Results

In 2007, 320 deaths were ascribed to PE in Australia, corresponding to a mortality rate of 1.73 per 100 000 population per year. Between 1997 and 2007, the Australian mortality rate decreased in both sexes, but this was significant only in females. By comparison, in 2009/10 there were 9,847 hospital separations for PE, corresponding to a rate of 53.1 per 100 000 population per year. In contrast to the fall in mortality rates, hospital separation rates significantly increased over the study period. Females had higher rates of morbidity and mortality from PE than males. While the mortality rates among the elderly population decreased significantly (from 48.4 to 34.3 per 100 000 population per year in those aged over 85 years), there were significant increases in PE mortality in the younger female age groups.

Conclusions

Although mortality rates are decreasing, PE remains a significant cause of morbidity and mortality in Australia, especially in females and the elderly. The burden of morbidity and mortality from PE in Australia is comparable to that found in America and a number of European countries.

Introduction

Pulmonary embolism (PE) is a common cause of morbidity and mortality [1], [2]. Although it is difficult to accurately assess the burden of disease in different populations, mortality rates are known to vary between countries [3]. While the PE mortality rate in the United States is estimated to be 3.8 per 100,000 [4] and in England 4.2 per 100,000 per year [5] the mortality rate is much lower in Asian countries due, in part, to the lower prevalence of genetic risk factors [6]. Over recent years, PE mortality has decreased in some countries such as England (a decrease of 27.6% between 1996 and 2005) and the United States (9.5% between 1990 and 1999) [3], [4], [7], [8], [9]. Paradoxically hospital admissions for PE have increased over this time in countries such as England, the United States, Denmark and China [5], [8], [10], [11]. To date, such trends have not been investigated in Australia.

Although understanding of the clinical and epidemiological characteristics of PE has increased over recent years, the state of knowledge regarding this important health problem remains incomplete. Analysis of disease-specific causes of morbidity and mortality, within and between countries and population sub-groups, allows clinicians and researchers to develop insights into the aetiology of PE, its clinical burden, and differences in clinical management over time and between groups. In the present study, we examined the patterns of morbidity and mortality due to PE in Australia between 1997 and 2010.

Section snippets

Methods

In Australia, information on all deaths (including age, sex and cause of death) is reported to the Registry of Births, Deaths and Marriages. These are processed, collated, and stored by the Australian Bureau of Statistics (ABS). The Australian Institute of Health and Welfare (AIHW) uses this data to compile tables of age and sex-specific causes of death in the General Record of Incidence of Mortality (GRIM) Books which are classified according to the International Classification of Diseases

Results

In 1997, there were 405 deaths from PE recorded in Australia, corresponding to an age-adjusted rate of 2.19 per 100,000 population. By comparison, fewer deaths (320) were recorded in 2007, corresponding to an age-adjusted rate of 1.73 per 100,000. More females than males died in 1997 (256 and 149 respectively). While the difference between the sexes remained, there were fewer female and male deaths (187 and 133 respectively) in 2007. After adjustment for age, the female death rate declined from

Discussion

In this study, we estimated that in 2007, Australia’s PE mortality rate was 1.73 per 100,000 population per year, lower than that reported for England (4.2 per 100,000 per year) [5] and the United States (3.8 per 100,000 per year) [4]. Internationally, patterns of PE mortality have been shown to vary over time and between populations [3]. In the United States and Canada, mortality from PE increased from the 1960s to the early 1980s, after which there was a decrease up to the late 1990s [4], [7]

Conflict of Interest Statement

This study is original work, which has not been submitted in part or in full elsewhere. There was no source of funding for this study, and all authors declare there is no potential conflict of interest capable of influencing judgment. The manuscript has been read and approved for submission by all authors, with all authors having full access to the data.

References (44)

B. Hoffmann et al.
Trends in mortality of pulmonary embolism–an international comparison
Thromb Res
(2010)
P. Aylin et al.
Trends in hospital admissions for pulmonary embolism in England: 1996/7 to 2005/6
Clin Med
(2008)
B. Park et al.
Recent trends in clinical outcomes and resource utilization for pulmonary embolism in the United States: findings from the nationwide inpatient sample
Chest
(2009)
P.D. Stein et al.
Estimated case fatality rate of pulmonary embolism, 1979 to 1998
Am J Cardiol
(2004)
D.E. Lilienfeld et al.
Mortality from pulmonary embolism in the United States: 1962 to 1984
Chest
(1990)
C.M. Butler et al.
Mortality trends from venous thrombosis and embolism in England and Wales
Lancet
(1983)
M.J. Goldacre et al.
Hospital admission and mortality rates for venous thromboembolism in Oxford region, UK, 1975-98
Lancet
(2000)
N.A. DeMonaco et al.
Pulmonary embolism incidence is increasing with use of spiral computed tomography
Am J Med
(2008)
A.J. Burge et al.
Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era
Clin Radiol
(2008)
P.Y. Scarabin et al.
Differential association of oral and transdermal oestrogen-replacement therapy with venous thromboembolism risk
Lancet
(2003)

M. Morpurgo et al.

The spectrum of pulmonary embolism. Clinicopathologic correlations

Chest

(1995)

W.K. Ho et al.

The incidence of venous thromboembolism: a prospective, community-based study in Perth, Western Australia

Med J Aust

(2008)

S. Sweetland et al.

Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study

BMJ

(2009)

K.T. Horlander et al.

Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data

Arch Intern Med

(2003)

M. Sakuma et al.

Increasing mortality from pulmonary embolism in Japan, 1951-2000

Circ J

(2002)

D.E. Lilienfeld

Decreasing mortality from pulmonary embolism in the United States, 1979-1996

Int J Epidemiol

(2000)

L. Mellemkjaer et al.

Admission for and mortality from primary venous thromboembolism in women of fertile age in Denmark, 1977-95

BMJ

(1999)

Y. Yang et al.

Pulmonary embolism incidence and fatality trends in chinese hospitals from 1997 to 2008: a multicenter registration study

PLoS One

(2011)

V.F. Tapson

Acute pulmonary embolism

N Engl J Med

(2008)

C.L. Soskolne et al.

Trends in pulmonary embolism death rates for Canada and the United States, 1962-87

CMAJ

(1990)

D. Kopcke et al.

Mortality from pulmonary embolism is decreasing in hospital patients

J R Soc Med

(2011)

S.H. Sheh et al.

Pulmonary embolism diagnosis and mortality with pulmonary CT angiography versus ventilation-perfusion scintigraphy: evidence of overdiagnosis with CT?

AJR Am J Roentgenol

(2012)

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The mortality associated with high-risk pulmonary embolism (PE) is remarkably high, and reperfusion to unload right ventricle should be a priority. However, several registries report reperfusion underuse. In Portugal, epidemiological data about the incidence, rate of reperfusion and mortality of high-risk PE are not known.
Nationwide population-based temporal trend study in the incidence and outcome of high-risk PE, who were admitted to hospitals of the National Health Service in Portugal between 2010 and 2018. High-risk PE was defined as patients with PE who developed cardiogenic shock or cardiac arrest. International Classification of Diseases (ICD), 9th and 10th revision, Clinical Modification codes, were used for data from the period between 2010 and 2016 (ICD-9-CM) and 2017–2018 (ICD-10-CM), respectively. The assessment focused on trends in the use of reperfusion treatment, which was defined by application of thrombolysis or pulmonary embolectomy. A comparison was made between the use or non-use of reperfusion therapy in order to examine trends in in-hospital mortality among high-risk PE cases.
From 2010 and 2018, there were 40.311 hospitalization episodes for PE in adult patients at hospitals of the National Health Service in mainland Portugal. There was a significant increase in the annual incidence of PE (41/100.000 inhabitants in 2010 to 46/100.000 in 2018; R²=0.582, p = 0.010). The average annual incidence was 45/100.000 inhabitants/year, with 2,7% of the PE episodes (1104) categorized as high-risk. The mortality rate associated with high-risk PE was high, although it has decreased over the years (74.2% in 2010 to 63.6% in 2018; R²=0.484; p = 0.022). Thrombolytic therapy was underused in high-risk PE, and its usage has not increased in recent years (17.3% in 2010 to 21.1% in 2018, R²=-0.127; p = 0.763). Surgical pulmonary embolectomy was used in 0.27% of cases, and there was no registry of catheter-directed thrombolysis. Patients with high-risk PE undergoing reperfusion therapy had lower in-hospital mortality compared to non-reperfused patients (OR=0.52; IC95% 0.38–0.70).
In Portugal, between 2010 and 2018, very few patients with PE developed high-risk forms of the disease, but the mortality rate among those patients was high. The low reperfusion rate could be associated with high in-hospital mortality and highlights the need to implement advanced therapies, as an alternative to systemic thrombolysis.
Association between exposure to air pollutants and the risk of hospitalization for pulmonary embolism in Beijing, China: A case-crossover design using a distributed lag nonlinear model
2022, Environmental Research
Pulmonary embolism (PE) is a life-threatening condition. Few studies have evaluated the relationship between air pollution and PE, and these results have been inconsistent. Therefore, our study aimed to investigate the association between air pollutant exposure and the risk of hospitalization due to PE.
Daily PE admissions, meteorological data, and ambient pollution data from January 1, 2015, to December 31, 2018, were collected in Beijing. A quasi-Poisson regression model combined with time-stratified case-crossover design and a distributed lag nonlinear model was used to determine the effect of air pollutant exposure on PE admission. To examine the stability of air pollutants' effects, multi-pollutant analyses were performed. Stratified analyses by age and sex were further conducted.
There were 5060 PE admissions during the study period, with an estimated incidence of 6.5 per 100,000. PM_2.5, PM₁₀, SO₂, O₃ and CO exposures were significantly associated with elevated risk of PE hospitalization. The highest cumulative risks were observed at a lag of 0–28 days for PM_2.5 (relative risk [RR] = 1.056, 95% confidence intervals [CI]: 1.015–1.098), PM₁₀ (RR = 1.042, 95%CI: 1.010–1.075), and CO (RR = 1.466, 95%CI: 1.127–1.906), at a lag of 0–27 days for SO₂ (RR = 1.674, 95%CI: 1.200–2.335), and at a lag of 0–4 days for O₃ (RR = 1.019, 95%CI: 1.001–1.038). All associations mentioned above except O₃ remained significant in multi-pollutant models. Stratified analyses showed that women and those aged ≥65 years people were more sensitive to PM₁₀ and CO exposure than men and those aged <65 years. The effect of PM_2.5 exposure was statistically significant in all subgroups.
Exposure to PM_2.5, PM₁₀, SO₂, and CO showed a positive association with PE hospitalization. High-risk PE groups should take special precautions on days with poor air quality.
E-selectin inhibitor is superior to low-molecular-weight heparin for the treatment of experimental venous thrombosis
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This study evaluated E-selectin inhibition with GMI-1271 (Uproleselan [GMI]) alone and in combination with the standard of care low-molecular-weight heparin (LMWH) to improve vein recanalization, decrease vein wall inflammation and protect against adverse bleeding in a primate model. We sought to examine this novel treatment of venous thrombosis.
Using a well-documented primate animal model, iliac vein thrombosis was induced by balloon occlusion of the iliac vein for 6 hours. Starting on day 2 after thrombosis, animals began treatment in two phases. In phase one, nontreated controls received no treatment (n = 5) vs animals treated with the E-selectin inhibitor GMI, 25 mg/kg, subcutaneous (SC), once daily (n = 4) for 21 days (previously published data). In phase two, animals were treated with GMI plus a combination of LMWH 1.5 mg/kg or 40 mg (GMI + LMWHc) SC once daily (n = 8) for 19 days; and animals treated with LMWH 1.5 mg/kg or 40 mg (LMWHc) SC once daily (n = 6) for 19 days. Animals were evaluated by magnetic resonance venography for vein recanalization and inflammation by gadolinium extravasation, duplex ultrasound, coagulation tests (thromboelastography, bleeding time, prothrombin time, activated partial thromboplastin time, fibrinogen) and complete blood count at baseline, days 2, 7, 14, and 21 at euthanasia. Statistical analysis included using unpaired t test with Welch's correction for direct comparisons and one-way analysis of variance for comparison between the groups.
Percent vein recanalization by magnetic resonance venography was highest in the GMI alone group followed by GMI + LMWHc, both significantly different from control. On ultrasound examination, animals treated with GMI alone had no decrease in open vein lumen by day 21, whereas decreases were observed in groups GMI + LMWHc (–26%), LMWHc (–27%), and controls (–80%). Vein wall inflammation decreased significantly in all treated groups. Intimal fibrosis and intimal thickness was best preserved in the GMI alone group. An analysis of total vein wall collagen revealed a trend in all treatment groups of decreasing vein wall collagen. No clinically significant bleeding events were noted in any group. The LMWH groups trended to have prolonged coagulation test values, whereas E-selectin inhibition with GMI did not cause clinically significant changes in coagulation measures.
Treatment with E-selectin inhibition results in improved vein recanalization, a decrease in vein wall inflammation and vein wall intimal thickness and fibrosis, with no changes in markers of coagulation. E-selectin inhibition with GMI alone is superior to E-selectin inhibition combined with LMWH, LMWH alone, and no treatment in this deep vein thrombosis model of iliac vein thrombosis.
Acute Pulmonary Embolism During Pregnancy and Puerperium: National Trends and In-Hospital Outcomes
2021, Mayo Clinic Proceedings
Citation Excerpt :
The principal findings were that acute PE occurred in ~1 of every 5,925 pregnancy-related hospitalizations; the rates of acute PE has remained unchanged during the study period; acute PE was independently associated with advanced maternal age ≥35 years, black race, and other cardiovascular risk factors; there was an increase in the prevalence of many risk factors for acute PE compared with those without PE; acute PE during pregnancy and puerperium was associated with ~200-fold increase in maternal in-hospital mortality rates, and such rates were not changed across the study duration; and advanced therapies were used in a small proportion of women with acute PE, including those with high-risk acute PE. Data from several developed countries indicate that the incidence of hospitalizations for acute PE in the general female population has been increasing or remained unchanged over the past decade.15,20-22 This analysis extended our knowledge by showing that although the rate of acute PE during pregnancy and puerperium remains low, these rates have not decreased.
To investigate the trend and outcomes of acute pulmonary embolism (PE) during pregnancy and puerperium using a large national database.
The National Inpatient Sample was queried to identify pregnancy-related hospitalizations in the United States from January 1, 2007, through September 30, 2015. Temporal trends in the rates of acute PE and in-hospital mortality rates were extracted.
Among 37,524,314 hospitalizations, 6,333 patients (0.02%) had acute PE. The prevalence of comorbidities and risk factors such as hypertension, obesity, and smoking increased, but rates of acute PE did not change significantly (18.01 in 2007 vs 19.36 in 2015, per 100,000 hospitalizations, P_trends=.21). Advanced therapies were used in a small number of women (systemic thrombolysis: 2.4%, surgical pulmonary embolectomy: 0.5%, and inferior vena cava filter in 8.3%). Rates of in-hospital mortality were almost 200-fold higher among those who had acute PE (29.3 vs 0.13, per 1000 pregnancy-related, P<.001). The rate of in-hospital mortality did not change among women with acute PE (2.6% in 2007 vs 2.5% in 2015, P_trends=.74).
In this contemporary analysis of pregnancy-related hospitalizations, acute PE was uncommon, but rates have not decreased over the past decade. Acute PE during pregnancy and puerperium was associated with high maternal mortality, and the rates of in-hospital mortality have not improved. Future studies to improve prevention and management of acute PE during pregnancy and puerperium are warranted.
Age-sex specific pulmonary embolism-related mortality in the USA and Canada, 2000–18: an analysis of the WHO Mortality Database and of the CDC Multiple Cause of Death database
2021, The Lancet Respiratory Medicine
Pulmonary embolism (PE)-related mortality is decreasing in Europe. However, time trends in the USA and Canada remain uncertain because the most recent analyses of PE-related mortality were published in the early 2000s.
For this retrospective epidemiological study, we accessed medically certified vital registration data from the WHO Mortality Database (USA and Canada, 2000–17) and the Multiple Cause of Death database produced by the Division of Vital Statistics of the US Centers for Disease Control and Prevention (CDC; US, 2000–18). We investigated contemporary time trends in PE-related mortality in the USA and Canada and the prevalence of conditions contributing to PE-related mortality reported on the death certificates. We also estimated PE-related mortality by age group and sex. A subgroup analysis by race was performed for the USA.
In the USA, the age-standardised annual mortality rate (PE as the underlying cause) decreased from 6·0 deaths per 100 000 population (95% CI 5·9–6·1) in 2000 to 4·4 deaths per 100 000 population (4·3–4·5) in 2006. Thereafter, it continued to decrease to 4·1 deaths per 100 000 population (4·0–4·2) in women in 2017 and plateaued at 4·5 deaths per 100 000 population (4·4–4·7) in men in 2017. Among adults aged 25–64 years, it increased after 2006. The median age at death from PE decreased from 73 years to 68 years (2000–18). The prevalence of cancer, respiratory diseases, and infections as a contributing cause of PE-related death increased in all age categories from 2000 to 2018. The annual age-standardised PE-related mortality was consistently higher by up to 50% in Black individuals than in White individuals; these rates were approximately 50% higher in White individuals than in those of other races. In Canada, the annual age-standardised mortality rate from PE as the underlying cause of death decreased from 4·7 deaths per 100 000 population (4·4–5·0) in 2000 to 2·6 deaths per 100 000 population (2·4–2·8) in 2017; this decline slowed after 2006 across age groups and sexes.
After 2006, the initially decreasing PE-related mortality rates in North America progressively reached a plateau in Canada, while a rebound increase was observed among young and middle-aged adults in the USA. These findings parallel recent upward trends in mortality from other cardiovascular diseases and might reflect increasing inequalities in the exposure to risk factors and access to health care.
None.
Trends in mortality related to pulmonary embolism in the European Region, 2000–15: analysis of vital registration data from the WHO Mortality Database
2020, The Lancet Respiratory Medicine
Citation Excerpt :
Furthermore, acute pulmonary embolism might occur under physiological states (for example, during pregnancy) or complicate elective surgical procedures that are characterised by negligible fatality. We observed a continuous decrease in pulmonary embolism-related mortality from 2000 to 2015, which is consistent with the decreasing trend reported by some,26,27,37,38 but not all,29,40 publications from mostly non-European countries in the 1990s and early 2000s. Possible explanations include improved venous thromboembolism prevention strategies in hospitalised patients,41,42 decreased case fatality due to improved treatment, and changes in entering vital registration data.
European estimates of the burden imposed by pulmonary embolism are not available to this date. We aimed to assess pulmonary embolism-related mortality and time trends in the WHO European Region.
We analysed vital registration data from the WHO Mortality Database (2000–15) covering subregions of the WHO European Region: Eastern Europe, Northern Europe, Southern Europe, Western Europe, and Central Asia. Deaths were considered pulmonary embolism-related if International Classification of Disease-10 code for acute pulmonary embolism (I26) or any code for deep or superficial vein thrombosis was listed as the primary cause of death. We used locally estimated scatterplot smoothing weighted by size of the Member State population to calculate proportionate mortality and time trends in age-standardised mortality.
In the 3-year period between 2013 and 2015, an average of 38 929 pulmonary embolism-related deaths occurred annually in the 41 Member States with available data and a population of 650 950 921; among individuals aged 15–55 years, pulmonary embolism accounted for 8–13 per 1000 deaths in women and 2–7 per 1000 deaths in men. Between 2000 and 2015, age-standardised annual pulmonary embolism-related mortality rates decreased linearly from 12·8 (95% CI 11·4–14·2) to 6·5 (5·3–7·7) deaths per 100 000 population without substantial sex-specific differences.
The observed decreasing trends in pulmonary embolism-related mortality might reflect improved management of the disease, in line with case fatality data from cohort studies. Additional, or alternative, explanations might include the absence of a uniform case definition and changes in coding practices and performing autopsy. Pulmonary embolism still imposes a relevant medical and societal burden. Continuing efforts are warranted to improve awareness and implement effective preventive and therapeutic measures.
German Federal Ministry of Education and Research.

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¹: Dr Timothy Shiraev completed this research as a medical student at the UNDA. He is currently a Junior Medical Officer at St George Hospital, Kogarah, Sydney.

²: Tel.: + 61 2 8382 6634; fax: + 61 2 8382 6652.

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Regular ArticleTrends in pulmonary embolism morbidity and mortality in Australia

Abstract

Introduction

Materials & Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conflict of Interest Statement

Thromb Res

Clin Med

Chest

Am J Cardiol

Chest

Lancet

Lancet

Am J Med

Clin Radiol

Lancet

Chest

The incidence of venous thromboembolism: a prospective, community-based study in Perth, Western Australia

Med J Aust

Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study

BMJ

Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data

Arch Intern Med

Increasing mortality from pulmonary embolism in Japan, 1951-2000

Circ J

Decreasing mortality from pulmonary embolism in the United States, 1979-1996

Int J Epidemiol

Admission for and mortality from primary venous thromboembolism in women of fertile age in Denmark, 1977-95

BMJ

Pulmonary embolism incidence and fatality trends in chinese hospitals from 1997 to 2008: a multicenter registration study

PLoS One

Acute pulmonary embolism

N Engl J Med

Trends in pulmonary embolism death rates for Canada and the United States, 1962-87

CMAJ

Mortality from pulmonary embolism is decreasing in hospital patients

J R Soc Med

Pulmonary embolism diagnosis and mortality with pulmonary CT angiography versus ventilation-perfusion scintigraphy: evidence of overdiagnosis with CT?

AJR Am J Roentgenol

Regular Article
Trends in pulmonary embolism morbidity and mortality in Australia