Sex-based differences in long-term respiratory and pulmonary vascular outcomes after acute pulmonary embolism: A propensity-matched analysis of 795,338 patients

BACKGROUND: Sex-based differences in long-term respiratory and pulmonary vascular outcomes after acute pulmonary embolism remain incompletely defined. OBJECTIVES: To compare long-term mortality, pulmonary vascular outcomes, and chronic respiratory sequelae between women and men after acute pulmonary embolism. METHODS: We conducted a retrospective cohort study and included adults diagnosed with acute pulmonary embolism from 2000 to 2025. A 90-day landmark analysis was used to examine long-term outcomes. Women and men were matched 1:1 by propensity scores based on demographic characteristics and baseline comorbidities. The primary outcome was all-cause mortality from 90 days to 3 years. Secondary outcomes included pulmonary hypertension, chronic thromboembolic pulmonary hypertension, chronic respiratory failure, long-term oxygen use, and right heart failure or chronic cor pulmonale. RESULTS: After matching, 397,669 women and 397,669 men were included. Women had lower 3-year all-cause mortality than men (9.50% vs. 9.97%; hazard ratio, 0.91; 95% CI, 0.90-0.93). Conversely, women had higher risks of pulmonary hypertension (3.16% vs. 2.73%; hazard ratio, 1.10; 95% CI, 1.07-1.13), chronic respiratory failure (1.96% vs. 1.61%; hazard ratio, 1.16; 95% CI, 1.12-1.20), and long-term oxygen use (2.65% vs. 2.20%; risk ratio, 1.21; 95% CI, 1.17-1.24). Chronic thromboembolic pulmonary hypertension was numerically more frequent among women but did not differ significantly in the 3-year time-to-event analysis. Right heart failure or chronic cor pulmonale did not differ significantly. Similar patterns persisted in 5-year analyses. CONCLUSIONS: Women demonstrated a distinct post-pulmonary embolism respiratory and pulmonary vascular outcome profile, with higher chronic pulmonary vascular and respiratory morbidity despite modestly lower long-term mortality.