Figure 1: Patient Flow Diagram
Figure 1: 367 patients with intermediate or high-risk pulmonary embolism admitted between 4/1/2019 and 4/1/2021 were included in the study, of whom 201 received PERT consults and 161 did not. Retrospective data were collected on all patients between time of discharge and 4/30/2023.
Three-hundred and sixty-seven patients with intermediate or high-risk PE were included in the study. Demographic and clinical characteristics of the cohort are presented in table 1. 263 (72%) of patients had echocardiographic evidence of right heart strain, and 221 (60%) had evidence of right heart strain on cross-sectional imaging (table 1) at the time of diagnosis of their PE. Of the 201 patients that received PERT consults (PCs), 139 (70%) were specifically referred to a dedicated PE-focused clinic on discharge, compared to 29 (18%) of the 161 non-PERT consult patients (NPCs) (P <0.001). Among PCs, 86 (44%) of patients attended at least one dedicated PE follow-up visit, compared with 16 (9.8%) NPCs (P <0.001). In the three months following discharge, 117 (60%) of PCs had a guideline-recommended discussion regarding anticoagulation agent and duration, compared with 48 (30%) of NPCs (P <0.001). In the cohort as a whole, 20 (5.5%) patients suffered a bleeding complication, 5 (1.4%) were diagnosed with CTED, and 15 (4.1%) with CTEPH during the follow-up period. The mean time to diagnosis of CTEPH or CTED was 14.7 (SD 11.5) months. In the overall cohort, 90 (25%) patients had died at the time of follow-up. Rates and causes of death are detailed in Appendix 4. At the time of follow-up, 107 of 367 patients had undergone a follow-up echocardiogram, 31 among NPCs and 76 among PCs. Among NPCs, 4(13%) patients had a larger RV at follow-up than at discharge, compared with 2(2.6%) PCs with increased RV size at follow-up. Additionally, 11(35%) of NPCs had a smaller RV at follow-up, compared with 43 (57%) of PC patients.
Table 1: Cohort Characteristics at Time of Discharge
Table 1: Cohort characteristics stratified by PERT consultation. COPD = Chronic Obstructive Pulmonary Disease, GI = gastrointestinal, PESI = Pulmonary Embolism Severity Index, GOC = Goals of Care, PERT = Pulmonary Embolism Response Team, IVC = Inferior Vena Cava, DVT = Deep Venous Thrombosis, AC = Anticoagulation
Table 2: Outcomes Post-Matching at 3 Months
Table 2: Propensity-matched outcomes at time of follow-up. PE = Pulmonary Embolism, VTE = Venous Thromboembolism
In the propensity-matched analysis, the odds ratio (OR) for follow-up referral was 11.8 (95% CI 6.6 – 21.2, P <0.001) among PCs, and 5.14 (95% CI 2.51 – 10.5, P <0.001) for attendance of a follow-up visit. The OR for guideline-recommended follow-up echocardiography was 3.36 (95% CI 1.89 – 5.97, P <0.001), and 2.63 (95% CI 1.5 – 4.6, P <0.001) for guideline-recommended discussion of anticoagulation. Following propensity matching there was no association between PERT consultation and bleeding complications (OR 1.19, 95% CI 0.4 – 3.5, P = 0.75) or readmission (OR 0.91, 95% CI 0.54 – 1.56, P = 0.74). There was a borderline-significant trend towards a greater likelihood of VTE recurrence among PCs (OR 3.8, 95% CI 0.99 – 14.8, P = 0.05). There was a significant decrease in odds of death at one year (OR 0.27, 95% CI 0.12 – 0.59, P = 0.001) and over the follow-up period (OR 0.63, 95% CI 0.39 – 0.99, P = 0.47). Kaplan-Meier analysis with a Cox PH model including age, sex, PESI score, use of home anticoagulation, history of COVID-19, congestive heart failure, chronic obstructive pulmonary disease, cirrhosis, and cancer showed a significant difference in mortality over the follow-up period (HR 0.44, 95% CI 0.28 -0.73, p = 0.001) favoring PCs when compared with NPCs. A simplified model containing only sex, age, and 2019 ESC-guideline risk group, also showed a significant difference in mortality (HR 0.48, 95% CI 0.3 – 0.75, p = 0.001) for PCs as compared to NPCs (Appendix 5).
Figure 2: Kaplan-Meier Survival Curve by PERT Consultation
Figure 2: Kaplan-Meier Curve of patient survival following index hospitalization for intermediate or high-risk pulmonary embolism. Patients that received PERT consults had an adjusted hazard ratio of 0.44 for all-cause mortality over the course of the study.