Jeffrey Endicott, BCCCP, PharmD
Pharmacist Clinician, Medical Intensive Care Unit
University of Vermont Medical Center, United States
Disclosure information not submitted.
MaryEllen Antkowiak, MD
Medical Director, Medical Intensive Care Unit
The University of Vermont Medical Center, United States
Disclosure information not submitted.
Title: OUTCOMES OF PATIENTS WITH HIGH-RISK SUBMASSIVE PULMONARY EMBOLISM RECEIVING FIBRINOLYTICS
INTRODUCTION/HYPOTHESIS:There are limited data on how to treat and stratify risk amongst patients with submassive pulmonary embolism (PE). Submassive PE is defined as a PE causing right ventricular dysfunction without hemodynamic instability. The European Society of Cardiology divides submassive PE into low and high-risk. The high-risk group has right ventricular dysfunction and evidence of myocardial injury while low-risk only has evidence of one. There are no studies that analyze the risk-benefit of fibrinolytics within these subgroups. The objective of this study was to compare the incidence of hemodynamic decompensation and bleeding in patients with high-risk submassive PE receiving fibrinolytics vs anticoagulation alone.
Methods: This retrospective, IRB approved study was conducted at the University of Vermont Medical Center. Patients admitted from October 2015 to August 2020 to the intensive care unit were included if they had a submassive PE with elevated troponin or brain natriuretic peptide, as well as evidence of syncope, hypoxemia, or a shock index of >0.9. The primary outcome was incidence of hemodynamic decompensation after 7 days of receiving treatment defined as a need for cardiopulmonary resuscitation, vasopressors, or a systolic blood pressure (SBP) < 90 mmHg or SBP drop > 40 mmHg lasting longer than 15 minutes. Secondary outcomes included the occurrence of moderate or severe bleeding, or intracranial hemorrhage (ICH).
Results: Fifty three patients were included. Twenty two patients received alteplase and thirty one patients received anticoagulation alone. Baseline characteristics and hemodynamics were similar between groups. Patients receiving alteplase had more episodes of syncope compared to those receiving anticoagulation, respectively (71.4% vs 37.5%; p< 0.016). There was no significant difference in hemodynamic decompensation between alteplase vs anticoagulation groups (0% vs 6.25%; p=0.76). Moderate bleeding occurred similarly between alteplase vs anticoagulation (3.1% vs 4.8%; p = 0.85). No evidence of severe bleeding or ICH occurred in either groups, although, there was one incidence of death in the anticoagulation group.
Conclusion: In patients receiving alteplase, fibrinolytics did not decrease the risk of hemodynamic decompensation in patients with a high-risk submassive PE compared to anticoagulation alone.