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Research Article | DOI: https://doi.org/10.31579/2641-0419/505
1Nisa-Garki Hospital, Abuja.
2Nnamdi Azikwe University Teaching Hospital, Nnewi.
3University of Abuja Teaching Hospital, Gwagwalada, FCT, Abuja.
4Veritas University Abuja.
*Corresponding Author: Ezinne Ijeoma Madubuonu, Nisa-Garki Hospital, Abuja.
Citation: Ezinne I. Madubuonu, Osita O. Irokansi, Ibikunle M. Durotoluwa, (2025), Clinical, Laboratory, and Imaging Determinants of Mortality in Hospitalized Patients with Pulmonary Embolism: A Retrospective Study, J Clinical Cardiology and Cardiovascular Interventions, 8(12); DOI:10.31579/2641-0419/505
Copyright: © 2025, Ezinne Ijeoma Madubuonu. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 30 July 2025 | Accepted: 08 August 2025 | Published: 13 August 2025
Keywords: pulmonary embolism; mortality; right ventricular dysfunction; troponin I; risk stratification; ctpa; thrombolysis; biomarkers
Background and Aim: Pulmonary embolism (PE) remains a major contributor to morbidity and mortality in hospitalized patients. This study aimed to identify clinical, laboratory, imaging, and treatment-related factors associated with in-hospital mortality among patients diagnosed with acute PE.
Method and Materials: A retrospective cohort study was conducted involving 59 patients with confirmed PE. Data collected included demographics, comorbidities, presenting symptoms, vital signs, laboratory parameters (including D-dimer, troponin I, and NT-proBNP), imaging findings (CT pulmonary angiography and echocardiography), electrocardiographic (ECG) features, and therapeutic interventions.
Results: The overall in-hospital mortality rate was 13.6%. Non-survivors were significantly older than survivors (mean age 62 vs. 49 years; p = 0.017) and had a higher prevalence of hypertension, tachycardia, hypotension, hypoxemia, and hemodynamic instability. Laboratory predictors of mortality included elevated D-dimer levels, positive troponin I, and increased NT-proBNP concentrations. Imaging findings associated with mortality included right ventricular (RV) dilation and an RV-to-left ventricular (LV) ratio >1 on CTPA.
In multivariate analysis, independent predictors of mortality were advanced age (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.02–1.18), hypertension (OR 3.00, 95% CI 1.10–8.20), tachycardia, hypotension, hypoxemia, hemodynamic instability (OR 5.00, 95% CI 1.80–13.90), and RV dilation (OR 2.80, 95% CI 1.05–7.50). Kaplan–Meier analysis revealed significantly reduced 30-day survival among patients with severe PE, comorbidities, or RV dysfunction (log-rank p < 0.05). Subgroup analyses indicated increased mortality risk in patients with severe PE and comorbidities. Female patients exhibited higher survival rates compared to males across all treatment categories. A notable but non-significant trend suggests thrombolysed males had worse outcomes, while thrombolysed females had better outcomes.
Conclusion: In patients with acute PE, independent predictors of mortality include advanced age, hypertension, tachycardia, hypotension, hypoxemia, hemodynamic instability, and right ventricular dysfunction. Laboratory markers of cardiac strain and imaging indicators of RV compromise are critical for effective risk stratification. Early identification and aggressive management of high-risk individuals are essential to improving clinical outcomes.
Pulmonary embolism (PE) is a life-threatening condition caused by the obstruction of pulmonary arteries, usually from a clot originating in the deep veins of the legs (DVT).[1] It remains a major cause of global morbidity and mortality, with 100,000 to 180,000 deaths annually in the U.S.[2] PE prevalence in sub-Saharan Africa and Nigeria varies due to diagnostic challenges, healthcare access, and evolving risk factors. In sub-Saharan Africa, PE prevalence among hospitalized patients ranges from 0.14% to 61.5%, with mortality rates between 18.4% and 69.5%.[3, 4] In Nigeria, a study of 31 patients confirmed via CTA showed a mean age of 55.5 years, with pregnancy as the most common risk factor (16.1%) and an in-hospital mortality rate of 9.7%.[5] This contrasts with higher mortality rates in other African regions, possibly due to smaller sample sizes or better diagnostics in tertiary centers. Notably, 48.4% of Nigerian cases lacked identifiable risk factors, suggesting diagnostic gaps or regional predispositions.5 Clinical factors such as age, comorbidities, and hemodynamic instability, along with imaging findings like right ventricular dysfunction and clot burden, are key predictors of mortality.[5, 6] Older patients, who often have additional comorbidities like cardiovascular disease or cancer, are at higher risk due to age-related changes in cardiovascular function. Early diagnosis and risk stratification are crucial to improving survival in PE patients.[7, 8]
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Comorbidities such as cardiovascular disease, cancer, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD) increase the mortality risk in PE patients.[9, 10] For example, individuals with active malignancy have a higher incidence of PE and worse outcomes due to the combined burden of cancer and thromboembolism.[11, 12] Similarly, patients with underlying heart disease, particularly those with reduced left ventricular function or heart failure, face higher mortality after PE.[13] Hemodynamic instability, such as hypotension, shock, or right ventricular dysfunction, is a strong predictor of mortality in PE. Severe hypotension can lead to right ventricular failure, significantly increasing the risk of early death if not treated with thrombolytics or surgical intervention.[8, 14] Acute respiratory failure, including hypoxemia and respiratory distress, is also associated with worse outcomes, especially when linked to massive PE or underlying respiratory disease.[15, 16]
Imaging is essential for the diagnosis, severity assessment, and prognosis of pulmonary embolism (PE). Beyond confirming the diagnosis, imaging particularly CT pulmonary angiography (CTPA) and echocardiography provides critical insights into disease severity.[17, 18] Right ventricular dysfunction (RVD) observed on imaging is a strong predictor of mortality, as it reflects the strain on the right heart due to obstructed pulmonary circulation.[19, 20] Studies show that patients with RVD or right ventricular dilation face significantly higher mortality risks, indicating a poorer prognosis and more severe PE. [19, 21]
The extent and location of thromboembolic material play a critical role in determining clinical outcomes in PE. Massive PE, involving large clots in the main pulmonary arteries, is linked to high mortality, while subsegmental PE, affecting smaller peripheral branches, generally has a better prognosis.[22] Larger clots are more likely to impair right ventricular function, often necessitating aggressive treatments like thrombolysis or surgical embolectomy.[23, 24]
Combining imaging findings with biomarkers enhances risk stratification. For example, elevated D-dimer levels correlate with greater clot burden, though not specific for predicting mortality on their own.[25, 26] However, when high D-dimer levels are paired with imaging evidence of extensive clot burden or right ventricular dysfunction, the risk of mortality rises significantly.[27] CT pulmonary angiography (CTPA) is the gold standard for PE diagnosis, offering detailed assessment of clot location and right ventricular involvement. [28, 29]
Treatment decisions in pulmonary embolism (PE) are guided by clinical and imaging findings, especially the severity of right ventricular dysfunction and clot burden. Thrombolytic therapy is commonly used in patients with massive PE or hemodynamic instability (e.g., hypotension or shock), and has been shown to reduce mortality compared to anticoagulation alone. [30, 31] However, due to the risk of major bleeding particularly in elderly or high-risk patients its use must be carefully considered.[32]
A key challenge in clinical practice is the limited integration of both clinical and imaging risk factors into existing prognostic models. Current tools may not capture all relevant variables, leading to inconsistent care and outcomes. Additionally, there is a lack of retrospective studies evaluating the combined impact of clinical co-morbidities, imaging findings, and biomarkers on mortality in PE.
This study aims to address these gaps by identifying specific clinical, imaging, and biomarker-related predictors of mortality in PE. It will assess the impact of co-morbidities, analyze the role of biomarkers, and explore how these factors influence outcomes. The findings could enhance current risk stratification models, enabling earlier identification of high-risk patients and supporting more targeted, aggressive treatments such as thrombolysis or surgical intervention to improve survival.
Study Population:
Inclusion Criteria:
Exclusion Criteria:
Variables:
Definition of terms
Descriptive statistics was used to summarize baseline characteristics, stratified by mortality outcomes. Categorical variables were compared using the Chi-square or Fisher’s exact test, while continuous variables were analyzed using the independent t-test or Mann-Whitney U test, as appropriate. Variables with a p-value Less-than sign 0.10 in univariate analysis was considered for inclusion in the multivariate model.
Binary logistic regression was employed to identify independent clinical and imaging predictors of mortality. Results were presented as adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Subgroup analyses were conducted based on PE severity, key comorbidities, and relevant imaging findings. Kaplan–Meier survival curves and the log-rank test were used to assess differences in survival across groups. All statistical analyses will be performed using SPSS, with significance set at p Less-than sign 0.05.
Ethical Considerations: Ethics Committee approval and informed consent waiver were obtained from Federal Capital Territory Health Research Ethics Committee
Demographic and Gender-Based Comparisons
The mean age of the cohort was similar between genders, with females having a mean age of 50.21years (SD = 13.9) and males 51.6 years (SD = 15.4). There were no statistically significant differences observed between males and females across the majority of clinical and laboratory variables. Although survival rates were slightly higher in females, men with pulmonary embolism experienced higher mortality (Table 1).
Clinical and Laboratory Characteristics of Non-Survivors
Patients who succumbed to pulmonary embolism (PE) were generally older and more likely to present with clinical features such as tachycardia, hypotension, hypoxemia, and hemodynamic instability (Table 2). These patients also exhibited elevated levels of D-dimer, troponin I, and NT-proBNP. Imaging finding such RV/left ventricular (LV) ratio >1 was more common among non-survivors, though these association did not achieve statistical significance in this sample.
Predictors of Mortality: Bivariate and Multivariate Analysis
In the bivariate analysis (Table 2), significant predictors of mortality included older age, hypertension, higher heart rate, lower systolic blood pressure, hemodynamic instability, elevated D-dimer, positive troponin I, and elevated NT-proBNP, and RV dilation on imaging. Electrocardiographic (ECG) findings and most traditional risk factors, with the exception of hypertension, were not significantly associated with mortality.
Multivariate logistic regression analysis further identified older age, hypertension, tachycardia, hypotension, hypoxemia, hemodynamic instability, and RV dilation on imaging as independent predictors of mortality in PE.
Subgroup Analysis
Subgroup analyses presented in Tables 4, and 5 offered further insights. Table 4 emphasized that severity of PE, particularly hemodynamic instability and hypoxemia, was the strongest predictor of mortality. Additionally, comorbidities such as hypertension, diabetes mellitus, chronic kidney disease (CKD), malignancy, and heart failure were found to independently increase the risk of death. Imaging evidence of RV dysfunction (RV dilatation) was associated with increased mortality, particularly in patients with severe PE.
Table 5 revealed notable, though statistically non-significant, trends. Among male patients, thrombolytic therapy was associated with a 100% mortality rate (2/2), whereas 75% of those treated with anticoagulants survived; however, this difference did not reach statistical significance (p = 0.10). In contrast, all female patients who received thrombolytics survived (4/4), with no significant difference in outcomes compared to those treated with anticoagulants (p = 0.56). A trend toward improved survival among thrombolysed females compared to males was observed, though this also failed to achieve statistical significance (p = 0.09)
Survival Analysis
Kaplan–Meier analysis (Table 6) showed an overall 30-day survival probability of 87% (95% CI: 73–92%). Survival rates were significantly lower among patients presenting with hemodynamic instability (log-rank p = 0.002), comorbidities (p = 0.03), and RV dilation on imaging (p = 0.04).
In the multivariate Cox proportional hazards model, increasing age (hazard ratio [HR]: 1.08 per year; 95% CI: 1.02–1.16; p = 0.01) and RV dilation on imaging (HR: 2.5; 95% CI: 1.1–5.8; p = 0.03) were identified as independent predictors of 30-day mortality.
| Variable | Male (n=24) | Female (n=35) | p-value |
| Demographics | |||
| Age, mean (SD), years | 51.6 (13.9) | 50.1 (15.4) | 0.37 |
| Smoking, n (%) | 6 (25.0) | 8 (23.5) | 0.89 |
| Clinical Presentation | |||
| Chest pain, n (%) | 11 (45.8) | 13 (37.1) | 0.50 |
| Breathlessness, n (%) | 21 (87.5) | 32 (91.4) | 0.62 |
| Cough, n (%) | 8 (33.3) | 13 (37.1) | 0.76 |
| Syncope, n (%) | 4 (16.7) | 3 (8.6) | 0.29 |
| Hemoptysis, n (%) | 3 (12.5) | 3 (8.6) | 0.68 |
| Leg pain, n (%) | 2 (8.3) | 7 (20.0) | 0.29 |
| Leg swelling, n (%) | 3 (12.5) | 8 (22.9) | 0.50 |
| Comorbidities | |||
| Hypertension, n (%) | 15 (62.5) | 15 (42.9) | 0.14 |
| Diabetes mellitus, n (%) | 5 (20.8) | 6 (17.1) | 0.75 |
| CKD, n (%) | 2 (8.3) | 1(2.9) | 0.56 |
| Malignancy, n (%) | 2 (8.3) | 2 (5.7) | 1.00 |
| Previous PE, n (%) | 5 (20.8) | 6 (17.1) | 0.75 |
| Previous DVT, n (%) | 9(37.5) | 7(20.0) | 0.15 |
| Heart failure, n (%) | 4 (16.7) | 7 (20.0) | 1.00 |
| Atria Fibrillation | 0(0.0) | 1(2.9) | 1.00 |
| Risk Factors | |||
| Recent immobilization, n (%) | 2(8.3) | 11 (25.7) | 0.54 |
| Recent surgery, n (%) | 6 (25) | 8 (22.9) | 1.00 |
| Pregnancy/Postpartum, n (%) | 0 (0.0) | 4 (11.4) | 0.12 |
| OCP use, n (%) | 0 (0.0) | 2 (5.7) | 0.51 |
| Vital Signs at Presentation | |||
| Heart rate, mean (SD), bpm | 96.0(19.4) | 103.91 (16.5) | 0.24 |
| Systolic BP, mean (SD), mmHg | 124.8 (21.4) | 126.5 (20.7) | 0.76 |
| Respiratory rate, mean (SD), bpm | 26.0 (6.3) | 29.3 (7.4) | 0.34 |
| Oxygen saturation, mean (SD), % | 88.4 (9.3) | 89.0 (6.9) | 0.16 |
| Laboratory Results | |||
| D-dimer, median (IQR), mg/L | 6.3 (3.5–9.2) | 5.1 (3.1–8.2) | 0.38 |
| Troponin I >0.1 ng/ml, n (%) | 5 (20.8) | 4 (11.8) | 0.33 |
| NT-proBNP >500 pg/ml, n (%) | 7 (29.2) | 11 (32.4) | 0.80 |
| WBC, median (IQR), x10⁹/L | 8.7 (6.2–11.4) | 8.2 (6.1–10.9) | 0.67 |
| Imaging Findings | |||
| RV dilation, n (%) | 7 (29.2) | 11 (31.4) | 0.98 |
| Pulmonary infarction, n (%) | 11 (45.8) | 16 (45.7) | 0.99 |
| RV/LV ratio >1, n (%) | 4 (16.7) | 6 (17.6) | 0.92 |
| Pulmonary hypertension, n (%) | 9(37.5) | 11 (31.4) | 0.78 |
| ECG Findings | |||
| Sinus tachycardia, n (%) | 12 (50.0) | 19 (54.3) | 0.89 |
| SIQ3T3, n (%) | 8 (75.0) | 5 (14.3) | 0.22 |
| RV strain, n (%) | 7 (29.2) | 9 (25.7) | 0.77 |
| RBBB, n (%) | 0 (0.0) | 1 (2.9) | 0.59 |
| Medications | |||
| Anticoagulants, n (%) | 24 (100.0) | 34 (97.1) | 0.70 |
| Thrombolytics n (%) | 2(8.3) | 4 (11.8) | 0.53 |
| Outcomes | |||
| Discharged alive, n (%) | 18 (75.0) | 33 (94.3) | 0.034 |
| Died, n (%) | 6 (25.0) | 2 (5.7) | 0.052 |
| Length of stay, median (IQR), days | 10 (7–15) | 10 (7–14) | 0.83 |
Table 1: Baseline Characteristics and Findings of Patients with Pulmonary Embolism
SD = standard deviation; IQR = interquartile range; BP = blood pressure; CKD = chronic kidney disease; DVT = deep vein thrombosis; OCP = oral contraceptive pill; RV = right ventricle; LV = left ventricle; RBBB = right bundle branch block.
| Variable | Survivors (n=51) | Non-survivors (n=8) | p-value* |
| Age, mean (SD) | 48.9 (13.7) | 62.1 (16.7) | 0.017 |
| Male, n (%) | 18(35.3) | 6 (75.0) | 0.37 |
| Chest pain, n (%) | 21 (41.2) | 3 (37.5) | 0.58 |
| Breathlessness, n (%) | 46 (90.2) | 7 (87.5) | 0.08 |
| Syncope, n (%) | 6 (11.8) | 1 (12.5) | 1.00 |
| Hypertension, n (%) | 25 (49.0) | 5 (62.5) | 0.80 |
| Diabetes, n (%) | 8 (15.7) | 3 (37.5) | 0.16 |
| Malignancy, n (%) | 3 (5.9) | 1 (12.5) | 0.45 |
| Immobilization, n (%) | 11(21.6) | 3 (37.5) | 0.26 |
| Heart Rate, mean (SD) | 99.7 (15.2) | 110.2 (17.6) | 0.027 |
| SBP, mean (SD), mmHg | 128.8 (19.3) | 110.4 (21.5) | 0.006 |
| O2 Sat, mean (SD), % | 90.8 (6.2) | 82.7 (7.7) | <0> |
| Hemodynamically stable, n (%) | 46 (90.2) | 6 (75.0) | 0.217 |
| D-dimer, median (IQR), mg/L | 5.1 (3.2–8.2) | 8.9 (6.8–>10) | 0.041 |
| Troponin I >0.1, n (%) | 5 (9.8) | 4 (50.0) | 0.038 |
| NT-proBNP >500, n (%) | 12 (23.5) | 6 (75.0) | 0.049 |
| RV dilation, n (%) | 17(33.3) | 1 (12.5) | 0.38 |
| RV/LV ratio >1, n (%) | 6 (11.8) | 4 (50.0) | 0.071 |
| Anticoagulants, n (%) | 50 (98.0) | 8 (100.0) | 0.69 |
| Thrombolytic | 4(7.84) | 2(25.0) | 0.13 |
| Length of stay, median (IQR), days | 10 (7–15) | 7 (4–10) | 0.044 |
Table 2: Baseline Characteristics Stratified by Mortality Outcome
SD = standard deviation; IQR = interquartile range; SBP = systolic blood pressure; O2 Sat = oxygen saturation; RV = right ventricle; LV = left ventricle
| Predictor | Odds Ratio (95% CI) | p-value |
| Age | 1.10 (1.02-1.18) | 0.01 |
| Male Sex | 2.50 (0.80-7.80) | 0.12 |
| Hypertension | 3.00 (1.10-8.20) | 0.03 |
| Heart Rate | 1.05 (1.01-1.10) | 0.02 |
| Systolic Blood Pressure | 0.95 (0.92-0.98) | 0.01 |
| Oxygen Saturation | 0.90 (0.85-0.95) | 0.001 |
| Hemodynamic Instability | 5.00 (1.80-13.90) | 0.001 |
| RV Dilation | 2.80 (1.05-7.50) | 0.04 |
Table 3: Multivariate Analysis of predictors of mortality in PE
| Subgroup | Key Predictor | Mortality (%) | p-value |
| Severity | Severe PE | 38 | <0> |
| Comorbidity | Any comorbidity | 27 | 0.04 |
| Imaging | RV dilation | 28 | 0.05 |
| Imaging | RV/LV ratio > 1 | 40 | 0.06 |
Table 4: Subgroup Analysis of Predictors of Mortality
| Gender | Medication | Discharged Alive, n (%) | Died, n (%) | Total (n) | Fisher’s Exact Test p-value |
| Male | Anticoagulants | 18 (75.0%) | 6(25.0%) | 24 | |
| Male | Thrombolytic | 0 (0.0%) | 2 (100%) | 2 | 0.10 |
| Female | Anticoagulants | 32(91.4%) | 2 (14.7%) | 34 | |
| Female | Thrombolytic | 4 (100%) | 0 (0%) | 4 | 0.56 |
| Gender comparison (thrombolytic survival) | — | — | — | — | 0.09 |
Table 5: Outcomes by Medication and Gender in Patients with Pulmonary Embolism
| Time (days) | Number at risk | Number of events | Survival probability (95% CI) |
| 0 | 59 | 0 | 1.00 (ref) |
| 7 | 59 | 2 | 0.97 (0.90–1.00) |
| 21 | 57 | 3 | 0.92 (0.83–0.97) |
| 30 | 54 | 3 | 0.87 (0.73–0.92) |
Table 6: Survival analysis
This retrospective analysis of 59 patients with pulmonary embolism (PE) provides a comprehensive assessment of demographic, clinical, laboratory, imaging, electrocardiographic, and therapeutic variables associated with in-hospital mortality. The observed mortality rate of 13.6% is consistent with previously reported data from cohorts of high-risk PE patients.[33] Multivariate analysis identified several independent predictors of mortality, including advanced age, hypertension, tachycardia, hypotension, hypoxemia, hemodynamic instability, and right ventricular (RV) dysfunction detected via imaging modalities.[33-35] Advanced age and hypertension likely contribute to reduced cardiac and systemic physiological reserves, whereas RV dysfunction reflects direct cardiac compromise secondary to PE. Collectively, these factors exert both independent and synergistic effects, substantially increasing the risk of in-hospital mortality among patients with acute PE. [36]
Patients who died were significantly older than survivors, with mean ages of 62 and 49 years, respectively. Age remained an independent predictor of mortality in multivariate models, corroborating prior studies that demonstrate increased vulnerability to adverse outcomes among elderly PE patients. [37-38] Hypertension was also more prevalent among non-survivors and independently associated with mortality, emphasizing the role of pre-existing cardiovascular comorbidities in PE prognosis.
Tachycardia, hypotension, and hypoxemia at presentation are well established clinical markers associated with increased mortality risk in acute PE. Among these, hemodynamic instability defined by hypotension or shock emerges as the strongest predictor, conferring up to a five-fold increased risk of death. This underscores the critical importance of prompt recognition and aggressive management of hemodynamically unstable PE patients to improve outcomes. Hemodynamic instability reflects severe RV dysfunction and systemic circulatory compromise due to pulmonary arterial obstruction, resulting in inadequate tissue perfusion and multi-organ failure. Numerous studies have consistently shown that patients presenting with shock or sustained hypotension exhibit the highest short-term mortality rates, warranting urgent interventions such as thrombolysis or surgical embolectomy.[14, 39, 40]
Moreover, tachycardia and hypoxemia represent compensatory physiological responses to hypoxia and circulatory stress, while also indicating a greater embolic burden and cardiopulmonary compromise. These clinical parameters are incorporated into validated risk stratification tools, such as the Pulmonary Embolism Severity Index (PESI) and the Pulmonary Embolism Mortality Score (PEMS), which predict 30-day mortality and guide therapeutic decision-making.[41]
In acute PE, elevated laboratory biomarkers—including D-dimer, troponin I, and NT-proBNP—are significantly associated with increased mortality, reflecting clot burden and myocardial strain. Elevated D-dimer levels indicate active thrombosis and fibrinolysis, while positive troponin I and raised NT-proBNP concentrations reflect myocardial injury and RV strain secondary to elevated pulmonary artery pressures. [7,25,41,42] These biomarkers are valuable for initial risk stratification and for identifying patients at higher risk of adverse outcomes.
However, multivariate analyses reveal that clinical and imaging markers particularly RV dysfunction and hemodynamic instability are more robust predictors of mortality. This suggests that, although laboratory biomarkers provide important prognostic information, their interpretation must be contextualized within the broader clinical picture, including patient symptoms, vital signs, and imaging findings. For example, RV dysfunction identified through echocardiography or computed tomography (CT) imaging directly reflects cardiac compromise and correlates strongly with mortality risk, often outperforming biomarkers alone.[25, 41] Hemodynamic instability, manifested as hypotension or shock, further delineates patients at highest risk who require urgent intervention.
Therefore, the integrated application of laboratory biomarkers in conjunction with clinical evaluation and imaging modalities enhances the accuracy of mortality prediction in acute PE. While laboratory markers serve as useful adjuncts, they are insufficient when used in isolation to guide prognosis or management decisions without consideration of the overall clinical context. [25, 41, 43]
Findings from this retrospective analysis are consistent with existing literature indicating no significant difference in overall or PE-related mortality between men and women, despite variations in clinical outcomes based on treatment. A large meta-analysis involving over 1.3 million patients found no sex-based difference in all-cause mortality or thrombolytic use (RR: 0.96, p = 0.66). [44] Other studies similarly report comparable survival rates and management strategies across sexes after adjusting for confounders.[44-46]
However, trends suggest that women may experience better survival following thrombolysis, albeit with increased risks of major bleeding and longer hospital stays. [44]. These differences may be attributed to distinct clinical presentations, including higher rates of RV strain and comorbidities among women, potentially affecting treatment response and complication rates. [45, 47] In this analysis, all thrombolysed females survived, whereas thrombolysed males exhibited poorer outcomes, reflecting possible sex-related physiological and therapeutic differences, though the small sample limits statistical inference.
These findings highlight the need for individualized, sex-informed risk stratification in PE management. While mortality does not significantly differ by gender, sex-specific factors such as bleeding risk and comorbidities should guide treatment decisions. Further research is warranted to clarify underlying mechanisms and refine gender-sensitive therapeutic approaches.[44]
This retrospective study was subject to several limitations. Selection bias may exist due to the inclusion of only hospitalized, confirmed PE cases, potentially omitting milder or undiagnosed cases. Unmeasured confounders, such as medication adherence and socioeconomic status, may have influenced outcomes. Variability in clinical practices, the single-center setting, and a limited sample size further restrict the generalizability of the findings. Prospective, multicenter studies are warranted to validate these results
In patients with acute pulmonary embolism (PE), independent predictors of in-hospital mortality include advanced age, pre-existing hypertension, tachycardia, hypotension, hypoxemia, hemodynamic instability, and right ventricular (RV) dysfunction. Laboratory biomarkers indicative of myocardial strain, alongside imaging evidence of RV compromise, play a pivotal role in accurate risk stratification. Timely identification of high-risk patients, coupled with prompt and targeted therapeutic intervention, is essential to optimizing clinical outcomes and reducing mortality.
Future Directions
To enhance the generalizability and clinical applicability of current findings, large-scale, multicenter studies are warranted to validate the identified predictors of mortality in acute pulmonary embolism. Additionally, further research should aim to identify and evaluate novel clinical, laboratory, and imaging-based risk factors to improve prognostic accuracy and inform evidence-based management strategies.
We declare no conflict of interest
We extend our sincere appreciation to Nisa-Garki Hospital for granting us permission to access their electronic medical records
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As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."
I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. I appreciate the journal (JCCI) editorial office support, the entire team leads were always ready to help, not only on technical front but also on thorough process. Also, I should thank dear reviewers’ attention to detail and creative approach to teach me and bring new insights by their comments. Surely, more discussions and introduction of other hemodynamic devices would provide better prevention and management of shock states. Your efforts and dedication in presenting educational materials in this journal are commendable. Best wishes from, Farahnaz Fallahian.
Dear Maria Emerson, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. I am delighted to have published our manuscript, "Acute Colonic Pseudo-Obstruction (ACPO): A rare but serious complication following caesarean section." I want to thank the editorial team, especially Maria Emerson, for their prompt review of the manuscript, quick responses to queries, and overall support. Yours sincerely Dr. Victor Olagundoye.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. Many thanks for publishing this manuscript after I lost confidence the editors were most helpful, more than other journals Best wishes from, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD
Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.
Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation, Auctores Publishing LLC, We would like to thank the editorial team for the smooth and high-quality communication leading up to the publication of our article in the Journal of Neurodegeneration and Neurorehabilitation. The reviewers have extensive knowledge in the field, and their relevant questions helped to add value to our publication. Kind regards, Dr. Ravi Shrivastava.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.
