VESS13 - Sex-based Differences in Presentation and Treatment of Pulmonary Embolism

Objectives: Pulmonary embolism (PE) incidence is higher in females; however, data on sex-based differences in clinical presentation and management remain limited and inconsistent. This study evaluated sex differences in the presenting severity and management of acute PE.

Methods: Hospitalizations for acute PE with a baseline echocardiogram across a multihospital healthcare system (2015–2025) were reviewed. High-risk PE was defined as hypotension (Systolic blood pressure < 90 mmHg), vasopressor requirement, or cardiac arrest; intermediate-risk PE was defined as elevated biomarkers (B-type Natriuretic Peptide or troponin) and/or right ventricular dysfunction on echocardiogram. Interventions included systemic therapies (systemic thrombolysis), targeted therapies (catheter-directed interventions or surgical embolectomy), and preventive therapies (inferior vena cava filters). Ordinal logistic regression and Fine–Gray competing-risk models were used to assess sex differences in PE severity and intervention receipt, respectively.

Results: Of 12,948 hospitalizations, 7,578 met inclusion criteria. Females (51.6%) were older (65.8±17.4 vs 63.0±15.4 years; p< 0.001) with a higher prevalence of obesity (37.5% vs 25.7%; p< 0.001). Low-risk PE accounted for 43.2% of hospitalization, intermediate-risk for 49.2%, and high-risk for 7.6% (Fig.1). After adjusting for cardiopulmonary comorbidities, chronic kidney disease, obesity, and age, female sex was significantly associated with lower PE severity on ordinal regression (Odds ratio: 0.80; 95% CI: 0.65–0.98).
Interventions occurred in 6.84% of hospitalizations (females: 6.2% vs males: 7.5%; p=0.02). Female sex was associated with a lower cumulative incidence of receiving an intervention (sub-distribution hazard ratio (sHR): 0.79; 95% CI: 0.64–0.98) when controlling for the competing risk of mortality, censoring at hospital discharge, and adjusting for the previously mentioned variables (Fig.2). After stratifying by PE severity, this sex difference in intervention receipt appeared to be primarily driven by the high-risk PE group (High-risk: sHR: 0.55, 95%CI: 0.34-0.89; Intermediate-risk: sHR: 0.94, 95%CI: 0.72-1.22; low-risk: sHR: 0.84, 95%CI: 0.52-1.37). Specifically, females were less likely to receive Inferior Vena Cava filter (7.02% vs 11.9%; p=0.048) or surgical embolectomy (1.1% vs 4.2%; p=0.019) when presenting with high-risk PE. Female sex was not associated with in‐hospital mortality after adjusting for severity of presentation (OR: 1.2; 95% CI: 0.91–1.62).

Conclusions: In patients hospitalized with PE, females present with lower severity PE compared males. Among patients with high-risk PE, females received lower rates of PE interventions. This suggests that there may be sex-based differences in presentation and treatment of PE.