Abstract

Background/Objectives: Acute pulmonary embolism (PE) is a major cause of cardiovascular mortality, with prognosis influenced by hemodynamic status, comorbidities, and biomarker profiles. Although several laboratory markers have demonstrated prognostic relevance in PE, it remains unclear whether their predictive performance differs in patients with active malignancy. This study aimed to identify laboratory predictors of in-hospital mortality in acute PE and evaluate the modifying effect of malignancy on biomarker-based prognostic stratification. Methods: This retrospective multicenter cohort study included 2803 consecutive patients with confirmed acute PE enrolled in the Regional Pulmonary Embolism Registry (REPER) between January 2015 and April 2026. Univariate and multivariable logistic regression analyses were performed to identify predictors of in-hospital mortality in the overall cohort and subgroups stratified by malignancy status. Interaction analyses were used to formally assess effect modification by malignancy. Results: Active malignancy was present in 14.02% of patients, and overall in-hospital mortality was 11.10%. Multivariable analysis identified malignancy, CRP, glucose, creatinine clearance (CrCl), platelet count, and ESC risk category as independent predictors of in-hospital mortality. In-hospital mortality was significantly higher in patients with malignancy compared with those without (16.54% vs. 10.21%, p < 0.001). In the malignant subgroup, CRP and glucose remained independent predictors, whereas in non-malignant patients, CRP, glucose, CrCl, and ESC risk category were independently associated with outcome. Significant interactions between malignancy status and CrCl, age, glucose, and total leukocyte count suggest that the prognostic contribution of these variables may differ according to cancer status. Conclusions: Active malignancy is an independent predictor of in-hospital mortality in acute PE and appears to be associated with a more severe presentation. Our findings suggest that malignancy may also modify the prognostic performance of certain biomarkers. These observations suggest that conventional risk stratification tools may require cautious, malignancy-aware interpretation and that prospective studies validating malignancy-adapted prognostic frameworks are warranted.

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