Advanced

interventions, outcomes, and complications in an intermediateand high-risk pulmonary embolism registry

Anthony J. Weekes, MD, MSc1* Ariana Trautmann, MD1† Parker Hambright, MD, 1† Angela Pikus MD, Shane Ali, MD1† Thomas Mathis3 Sarah Bradford MS2 Nicole Wellinsky,4 Nathaniel S. O’Connell, PhD2

1Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, North Carolina

2Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston- Salem North Carolina, USA

Objective: To determine which patients with pulmonary embolism (PE) received advanced interventions versus anticoagulation monotherapy, and to compare outcomes and complications between the treatment groups.

Methods: We conducted a secondary analysis of a registry of intermediate- and highrisk adult PE patients treated at one of 11 regional EDs from August 2016 to November 2022. Predictors of interest were PE severity and bleeding risk. The primary outcome was treatment approach, expressed as anticoagulation monotherapy, advanced intervention delayed (> 12 hours) and immediate (less than or at 12 hours). Secondary outcomes were in-hospital clinical deterioration (including death) and major bleeding complications.

Results: There were 1832 eligible patients in the registry (age 62.8 [SD 16.2] years; 48.2% male). For PE severity at presentation, 7.6% were high-risk, 38.6% intermediatehigh, 53.3% intermediate-low, and 0.5% low risk. Bleeding risk assessments were classified as high, moderate, and low for 13.5%, 49.9%, and 36.5% of patients, respectively. Advanced PE interventions were administered to 62.6%, 27.6%, and 11.2% of high-risk, intermediate-high, and intermediate-low risk patients, respectively. Subsequent clinical deterioration occurred in 77.0%, 10.8%, and 3.4% of high-risk, intermediate-high, and intermediate-low risk patients, respectively (p <0.001). Major bleeding occurred in 4.2% on anticoagulation monotherapy versus 17.6% of patients who received advanced PE interventions (p <0.001).

Conclusions: Close to 40% of high-risk PE patients did not receive advanced PE intervention, whereas over a quarter of intermediate-high risk did. Up to 10% of intermediate-high risk patients experienced clinical deterioration. The incidence of major bleeding was higher among those with advanced PE intervention than those on anticoagulation monotherapy.