RETROSPECTIVE ANALYSIS OF PATIENTS WITH INTERMEDIATE- AND HIGH-RISK PULMONARY EMBOLISM: DEMOGRAPHICS, MANAGEMENT, AND OUTCOMES FROM A LARGE ACADEMIC REFERRAL CENTER

SESSION TITLE: Novel Insights Into CTEPH Management SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/10/2023 12:55 pm - 01:40 pm PURPOSE: Risk stratification for pulmonary embolism (PE) has changed in recent years and has significantly impacted management and prognosis. Here we compare clinical features, management, and outcomes between patients with low-risk, intermediate-low, intermediate-high, and high-risk PE, treated at a high-volume academic center. In addition, we compare characteristics and outcomes in patients undergoing treatment with heparin alone, catheter-directed thrombolysis (CDT), percutaneous mechanical thrombectomy (PMT) and systemic thrombolytics. METHODS: We retrospectively analyzed data from 192 cases treated by our institutional pulmonary embolism response team from 2018-2022. Clinical data was collected and manually curated from the electronical medical record system. Patients were stratified based on presence and severity of right ventricular dysfunction and hemodynamic instability. Survival time was calculated from time of PERT note until last clinical encounter or death. We analyzed the risk of a clinical composite endpoint of death within 90-days, cardiac arrest, ECMO, or vasopressors need using Cox proportional Hazards. RESULTS: 192 patients were studied. The cohort was predominantly White (65%) males (52.6%) with a median age of 64 years (IQR 24). Patients were stratified as low-risk (10%), intermediate-low (15.6%), Int-high (52.6%), and high-risk (20.8%). Median PESI score was 110 (IQR 60). 60.4% had a concurrent DVT. Excluding low-risk patients, heparin monotherapy was used in 53.3%, 26.7% and 20% of patients with intermediate-low, intermediate-high and high-risk PE, respectively. Similarly, CDT was used in 23%, 44% and 32% and PMT in 20%, 30% and 25%, respectively. Systemic thrombolytics were used in 20% of patients with high-risk PE. Seven patients (3%) had a neurological complication such as ischemic stroke(n=4) or intracranial hemorrhage(n=3). 5.2%(n=6) suffered a major bleeding complication. Forty-four patients died (23.4%) and 76.6% were alive or lost follow-up. Median follow-up time for the cohort was 11.53 months (IQR25.13). 58 patients (30%) met the composite endpoint, out of which 67% were high-risk (n=39), intermediate-high 19% (n=11), intermediate-low 10.3%(n=6) and 3.45%(n=2) were low-risk. High-risk patients had the worst outcomes. We found no difference in death probability between intermediate-low versus intermediate-high risk patients. However, both intermediate-risk strati had a significant difference in meeting the composite endpoint compared to low-risk PE. Including only intermediate-risk PE patients, patients treated with CDT (HR 0.55, 95%CI 0.164-1.86, p=0.339) and PMT (HR 0.817, 95%CI 0.230-2.90, p=0.754.) exhibited a trend towards lower risk of meeting composite outcome compared to heparin monotherapy. However, including only high-risk and intermediate-high risk patients, CDT exhibited a lower risk of meeting the composite outcome compared to heparin monotherapy (HR 0.364, CI 0.155-0.854, p=0.021) CONCLUSIONS: Stratifying patients based on features of right ventricular dysfunction identifies patients at higher risk of worse clinical outcomes. In patients with intermediate-high and high-risk PE, CDT is associated with a lower risk of meeting a composite outcome of death within 90 days, cardiac arrest, ECMO, or vasopressor need. In patients with intermediate-risk PE, CDT and PMT exhibited a lower risk of meeting the composite outcome, but this was not statistically significant. CLINICAL IMPLICATIONS: Risk stratification including intermediate-risk category identifies patients with worse outcomes and has an impact on management strategies. DISCLOSURES: No disclosure on file for Saad Ahmad No relevant relationships by Suzanne Bennett Research - Paid directly to UC relationship with United Therapeutics, Gossamer Bio, Bayer, Acceleron/Merck Please note: Ongoing Added 03/27/2023 by Jean Elwing, source=Web Response, value=Grant/Research Support Research - Paid directly to UC relationship with Altavant, Aerovate, Tenax, Pharmosa, Actelion/Janssen, Lung Please note: Ongoing Added 03/27/2023 by Jean Elwing, source=Web Response, value=Grant/Research Support Advisory Committee Member relationship with Liquida, Acceleron/Merck Please note: To complete 5/23 Added 03/28/2023 by Jean Elwing, source=Web Response, value=Consulting fee Advisor / Grant Reviewer (Ongoing 3/23) relationship with Bayer Please note: Ongoing Grant Review Added 03/27/2023 by Jean Elwing, source=Web Response, value=Consulting Fee and Honoraria Advisory Committee Member relationship with Bayer Please note: Complete 11/22 Added 03/28/2023 by Jean Elwing, source=Web Response, value=Consulting fee Removed 03/28/2023 by Jean Elwing, source=Web Response unknown relationship with United Therapeutics Please note: Intermittent Added 03/28/2023 by Jean Elwing, source=Web Response, value=Consulting fee Removed 03/28/2023 by Jean Elwing, source=Web Response Advisory Committee Member relationship with United Therapeutics (ongoing advising / education with speaking) Please note: Intermittent Added 03/28/2023 by Jean Elwing, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Altavant, Aerovate, Gossamer Bio (complete 12/21), Janssen (complete 3/23), Insmed (complete 12/22) Please note: Complete 3/23 Added 03/28/2023 by Jean Elwing, source=Web Response, value=Consulting fee Research - Paid directly to employer relationship with Altavant, Aerovate, Tenax, Pharmosa Please note: Ongoing Research Added 03/31/2023 by Jean Elwing, value=Grant/Research Support Research - Paid directly to employer relationship with Janssen, United Therapeutics, Liquidia, Phase Bio, Gossamer Bio, Bayer, Acceleron/Merck Please note: Ongoing Research Added 03/31/2023 by Jean Elwing, value=Grant/Research Advisory Committee Member relationship with Altavant, Aerovate, Bayer, Gossamer Bio, Liquida, Acceleron/Merck, Janssen, Insmed Please note: All complete before 4/23 Added 03/31/2023 by Jean Elwing, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: Ongoing Added 03/31/2023 by Jean Elwing, value=Consulting fee Speaker/Speaker's Bureau relationship with United Therapeutics Please note: 2022-2023 Added 03/31/2023 by Jean Elwing, source=Web Response, value=Honoraria Removed 03/31/2023 by Jean Elwing, source=Web Response NonCME Speaker (Complete 4/23) relationship with United Therapeutics Please note: End 4/23 Added 03/31/2023 by Jean Elwing, source=Web Response, value=Honoraria No relevant relationships by Jose Gomez-Arroyo No relevant relationships by Will Jensen Entelligence Young Investigator Award relationship with Actelion/Janssen Please note: 3/2020 to 3/2022 by Arun Jose, value=Grant/Research Support Investigator Sponsored Study Grant relationship with United Therapeutics Please note: 6/2020 to current by Arun Jose, value=Grant/Research Support No relevant relationships by Kara Kaplan No relevant relationships by Dana Kay No relevant relationships by Louis Louis No relevant relationships by Evan Ramser