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Pulmonary Vascular Disease |

Outcomes of Patients With Intermediate Risk Pulmonary Embolism

Anish Desai, MBBS; Amishi Desai, MBBS; Joseph Mathew, MD
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Winthrop University Hospital, Mineola, NY


Chest. 2015;148(4_MeetingAbstracts):998A. doi:10.1378/chest.2281757
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Abstract

SESSION TITLE: Venous Thromboembolism Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Intermediate risk pulmonary embolism (PE) is defined as acute PE leading to right ventricular dysfunction, diagnosed by echocardiography or computed tomographic (CT) scan. Treatment for intermediate PE is controversial and various options exist including local and systemic thrombolytics in addition to anticoagulation. To clarify this issue further, we report a case series of intermediate risk PE at our institution.

METHODS: From January 2011 to July 2014, a total of 1554 patients presented with newly diagnosed venous thromboembolism (VTE), out of which 31 patients with intermediate risk acute PE without contraindication to anticoagulation were identified. Data regarding their demographics, type of anticoagulation, insertion of inferior vena cava (IVC) filter, troponin I and brain natriuretic peptide (BNP) levels, bleeding events and readmission rates were retrospectively analyzed.

RESULTS: Out of the 31 patients, 15 (48%) were initially treated with enoxaparin and the remainder with unfractionated heparin. Two patients received systemic half dose thrombolytics (altepase 50mg). Twelve (39%) received rivaroxaban and the rest received warfarin or warfarin with enoxaparin upon discharge. Deep vein thrombosis (DVT) was found in 22 patients (71%) and an IVC filter was inserted in 9 (41%) of these patients. Eighteen (58%) were observed in the intensive care unit (ICU). None of the patients had further hemodynamic deterioration or death. There were no bleeding events during the hospitalization and all patients survived to discharge. Patients treated with rivaroxaban had a shorter length of stay as compared to warfarin (5 vs. 7 days, p value - 0.0372). One patient discharged on warfarin was readmitted with a new VTE within 6 months. None of the patients underwent catheter directed thrombolysis or surgical embolectomy.

CONCLUSIONS: In this case series, patients treated with unfractionated heparin and enoxaparin did not have hemodynamic deterioration or increased mortality outcomes, despite not receiving full dose thrombolytics. Insertion of an IVC filter did not affect clinical outcomes. Use of rivaroxaban upon discharge led to a shorter length of stay without any adverse outcomes.

CLINICAL IMPLICATIONS: In patients admitted with intermediate risk PE, initial treatment with unfractionated heparin or enoxaparin and later bridging to rivaroxaban may lead to shorter length of stay as compared to warfarin. Rivaroxaban is safe to use in intermediate risk PE. It is unclear whether IVC filter affects outcomes.

DISCLOSURE: The following authors have nothing to disclose: Anish Desai, Amishi Desai, Joseph Mathew

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