• Ariel Dahan, Sergio Farina, Natasha E Holmes, Stefan Kachel, Christine F McDonald, Jane E Lewis, Nada Marhoon, Fumitaka Yanase, Natalie Yang, and Rinaldo Bellomo.
• Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia.
• Intern Med J. 2023 Aug 1; 53 (8): 143514431435-1443.

BackgroundAnticoagulation for subsegmental pulmonary embolism (SSPE) is controversial.AimTo assess the impact of clinical context on anticoagulation and outcomes of SSPE.MethodsWe electronically searched computed tomography pulmonary angiogram reports to identify SSPE. We extracted demographic, risk factor, investigations and outcome data from the electronic medical record. We stratified patients according to anticoagulation and no anticoagulation.ResultsFrom 1 January 2017 to 31 December 2019, we identified 166 patients with SSPE in 5827 pulmonary angiogram reports. Of these, 123 (74%) received anticoagulation. Compared with non-anticoagulated patients, such patients had a different clinical context: higher rates of previous venous thromboembolism (11% vs 0%; P = 0.019), more recent surgery (26% vs 9%; P = 0.015), more elevated serum D-dimer (22% vs 5%; P = 0.004), more lung parenchymal abnormalities (76% vs 61%; P = 0.037) and were almost twice as likely to require inpatient care (76% vs 42%; P < 0.001). Such patients also had twice the all-cause mortality at 1 year (32% vs 16%).ConclusionsSSPE is diagnosed in almost 3% of pulmonary angiograms and is associated with high mortality, regardless of anticoagulation, due to coexistent disease processes rather than SSPE. Anticoagulation appears dominant but markedly affected by the clinical context of risk factors, alternative indications and illness severity. Thus, the controversy is partly artificial because anticoagulation after SSPE is clinically contextual with SSPE as only one of several factors.© 2022 Royal Australasian College of Physicians.

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