Anticoagulation Use in Septic Pulmonary Embolism: Prevalence, Outcomes, and Insights From a National Inpatient Analysis

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Abstract RATIONALE: Anticoagulation is generally avoided in septic embolization due to increased bleeding risk. Given limited data and reliance on observational studies, this study assesses the prevalence and outcomes of anticoagulation use in a nationally representative cohort of septic pulmonary embolism (SPE). METHODS: Adult hospitalization records from the 2021 National Inpatient Sample were weighted to represent national estimates. Multivariable Cox regression models, adjusted for demographics, hospital characteristics, and comorbidities, assessed the impact of anticoagulation on clinical outcomes in SPE. RESULTS: Compared to hospitalized patients without SPE, matched 1:1 by baseline characteristics, patients with SPE (n=14,695, 41.38±0.27 years, 48.59% female) had significantly higher rates of substance use disorder (69.41% vs. 43.04%), surgical (54.61% vs. 28.17%) procedure, infectious endocarditis (46.38% vs. 0.58%), sepsis syndrome (43.08% 5.85%), central venous catheter (33.41% vs. 4.80%), heart failure (18.31% vs. 8.13%), skin and soft tissue infection (17.97% vs. 5.78%), mild liver disease (17.05% vs. 6.67%), deep vein thrombosis (9.66% vs. 1.02%), cardiovascular device (9.49% vs. 5.61%), pulmonary embolism (8.30% vs. 3.44%), cerebrovascular accident (8.06% vs. 3.16%), myocardial infarction (6.94% vs. 4.36%), odontogenic disease (5.38% vs. 1.40%), congenital heart disease (4.32% vs. 0.78%), tricuspid (3.91% vs. 0.14%) and pulmonary (0.58% vs. 0.03%) valve disease, dental (2.04% vs. 0.27%), and HIV/AIDS (1.26% vs. 0.31%). Anticoagulation was used in 4.87%, while inferior vena cava filters, thrombolytics, and embolectomies were performed in 0.75%, 0.68%, and 0.07% of SPE cases, respectively. In comparison with unmatched controls (n=14,925), the anticoagulated SPE cohort (n=745) was older (46.50±1.41 vs. 41.08±0.27 years) and had higher rates of heart failure (30.20% vs. 17.79%), cardiovascular device (26.17% vs. 8.54%), pulmonary embolism (25.50% vs. 7.34%), obesity (17.45% vs. 9.28%), myocardial infarction (14.09% vs. 6.67%), and steroid use (9.40% vs. 1.64%) (all p<0.001) (Table 1). The anticoagulated group had shorter stay (13.48±1.01 vs. 17.38±0.31 days, p<0.001) and reduced in-hospital mortality (3.36% vs. 9.11%, p=0.02) (Table 1). Anticoagulation lacked association with hypovolemic shock, cardiogenic shock, cardiac arrest, respiratory failure, extracorporeal membrane oxygenation (ECMO) use, and in-hospital mortality in patients with SPE, while those untreated with anticoagulation had higher odds of respiratory failure (adjusted odds ratio [aOR] 1.72, 95% confidence interval [CI] 1.56-1.89) and ECMO use (aOR 2.34, 95% CI 1.53-3.57) (both p<0.001). CONCLUSIONS: Our nationwide cohort study suggests that anticoagulation in SPE is uncommon but may improve outcomes in carefully selected patients without significantly increasing adverse events.

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