PURPOSE:Anticoagulation is the mainstay of therapy for patients with acute pulmonary embolism (PE). Treatment with thrombolytics or pulmonary embolectomy has been advocated for patients suffering PE and high-risk features for morbidity or mortality without definitive evidence of benefit when compared to anticoagulation and supportive care alone. Our objective was to compare the outcome of intensive care unit (ICU) patients with a primary diagnosis of PE treated with anticoagulation or thrombolysis/surgical embolectomy.
METHODS:All patients admitted to our multi-disciplinary ICU over 9 years with a diagnosis of PE were identified retrospectively from the hospital APACHE database. Patients who received heparin/coumadin (group 1) or lytics/embolectomy (group 2) were included. Groups were compared by wilcoxon rank sum and chi-squares for continuous and categorical variables, respectively. Significance was a two-sided p value≤;0.05. Logistic regression with hospital mortality as the independent variable was performed including age, gender, cardio-pulmonary disease (CPD), hemodynamics, APACHE III score, and treatment assignment as explanatory variables.
RESULTS:133 patients were included (group 1=109, group 2=24). Overall, 45% presented from the community, 46% from within the hospital, and 9% from outside transfers. Age, gender, and APACHE III were similar between groups. A greater proportion of group 1 had pre-existing CPD (18.1% v. 4.5%), while group 2 experienced more shock at presentation (37.5% v. 17.4%) and hemodynamic instability within the 6 hours from presentation (8.3% v. 4.5%). Mortality, length of stay (LOS), discharge disposition, and total cost were similar between groups, but group 1 had significantly lower than predicted ICU mortality (SMR=0.36, 95% CI 0.07–1.05, p=0.03) while group 2 did not (SMR=1.11, 95% CI 0.23–3.25, p=0.51). Treatment assignment did not explain mortality by regression modeling.
CONCLUSION:Thrombolytics/embolectomy did not improve outcomes compared to predicted in our patients while anticoagulated patients did better than expected.
CLINICAL IMPLICATIONS:In PE, traditional anticoagulation and supportive care alone results in similar outcomes to those treated with more aggressive therapy. The role of lytics and surgery require further definition.
DISCLOSURE:Aaron Joffe, No Financial Disclosure Information; No Product/Research Disclosure Information