Bikdeli Behnood, Leyva Hannah, Muriel Alfonso, Lin Zhenqiu, Piazza Gregory, Khairani Candrika D, Rosovsky Rachel P, Mehdipour Ghazaleh, O'Donoghue Michelle L, Madridano Olga, Lopez-Saez Juan Bosco, Mellado Meritxell, Diaz Brasero Ana Maria, Grandone Elvira, Spagnolo Primavera A, Lu Yuan, Bertoletti Laurent, López-Jiménez Luciano, Jesús Núñez Manuel, Blanco-Molina Ángeles, Gerhard-Herman Marie, Goldhaber Samuel Z, Bates Shannon M, Jimenez David, Krumholz Harlan M, Monreal Manuel
Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Vasc Med. 2025 Feb;30(1):58-66. doi: 10.1177/1358863X241292023. Epub 2024 Nov 26.
Sex differences exist in risk factors and comorbidities of older adults (aged ⩾ 65 years) with pulmonary embolism (PE). Clinically relevant sex-based treatment disparities for PE have not been adequately addressed. The few existing show conflicting results due to small sample size (type II error) and suboptimal methods (overreliance on -value, which may detect differences of small clinical relevance).
We assessed sex differences in anticoagulation and advanced therapies for PE in older adults, utilizing data from Registro Informatizado Enfermedad TromboEmbolica (RIETE), a large PE registry with predominant participation from Europe, and data from US Medicare beneficiaries. We prespecified a standardized difference (SRD) > 10% as clinically relevant. RIETE included 33,462 (57.7% female) and Medicare included 102,391 (55.0% female) older adults with PE.
In RIETE, there were no overall sex differences in the use of anticoagulation (median: 181 vs 180 days, SRD < 1%), fibrinolysis (SRD < 3%), thrombectomy (SRD < 2%), or inferior vena cava (IVC) filters (SRD: 4.4%). However, fibrinolytic therapy (systemic or catheter-based) was less often used in female than male patients with intermediate-risk PE (8.0% vs 12.1%, SRD: 13.6%). No sex differences were noted with advanced PE therapies in Medicare beneficiaries. In unadjusted analyses, fibrinolysis and IVC filter placement were more frequent in Medicare than RIETE participants regardless of sex ( < 0.001).
In a predominantly European PE registry and a US study of older adults, there were no overall sex differences in anticoagulation patterns or advanced therapy utilization. Future studies should determine if sex disparities in fibrinolytic therapy for intermediate-risk PE and greater use of advanced therapies in US older adults correlate with clinical outcomes.
65岁及以上的老年肺栓塞（PE）患者在危险因素和合并症方面存在性别差异。PE基于性别的临床相关治疗差异尚未得到充分解决。现有的少数研究由于样本量小（II类错误）和方法欠佳（过度依赖P值，可能检测到临床相关性小的差异）而结果相互矛盾。
我们利用来自欧洲占主导地位的大型PE登记处Registro Informatizado Enfermedad TromboEmbolica（RIETE）的数据以及美国医疗保险受益人的数据，评估老年PE患者在抗凝和高级治疗方面的性别差异。我们预先设定标准化差异（SRD）>10%为具有临床相关性。RIETE纳入了33462名老年PE患者（女性占57.7%），医疗保险纳入了102391名老年PE患者（女性占55.0%）。
在RIETE中，抗凝治疗的使用（中位数：181天对180天，SRD<1%）、纤维蛋白溶解治疗（SRD<3%）、血栓切除术（SRD<2%）或下腔静脉（IVC）滤器的使用（SRD：4.4%）在总体上没有性别差异。然而，在伴有中度风险PE的女性患者中，纤维蛋白溶解治疗（全身或基于导管）的使用频率低于男性患者（8.0%对12.1%，SRD：13.6%）。在医疗保险受益人中，高级PE治疗未发现性别差异。在未调整的分析中，无论性别，医疗保险参与者中纤维蛋白溶解治疗和IVC滤器置入的频率均高于RIETE参与者（P<0.001）。
在一个以欧洲为主的PE登记处和一项针对美国老年人的研究中，抗凝模式或高级治疗的使用在总体上没有性别差异。未来的研究应确定中度风险PE的纤维蛋白溶解治疗中的性别差异以及美国老年人中更频繁使用高级治疗是否与临床结果相关。
