Management of Intermediate High-Risk Pulmonary Embolism: A Single -Center Retrospective Study

Fortune O Alabi^1*Ashkan Ghaneie²Ibrahim Koury²Hadaya Ali Alkhateeb³Jieying Liu⁴Mengni Guo⁵Baha Aldeen B Fawwaz²Arelis Cordero¹Fred Umeh¹

• ¹Florida Lung Asthma and Sleep Specialists, Kissimmee, United States
• ²Advent Health Orlando, Orlando, Florida, United States
• ³Philadelphia College of Osteopathic Medicine (PCOM), Philadelphia, United States
• ⁴Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee, United States
• ⁵School of Medicine, Loma Linda University, Loma Linda, California, United States

Introduction: Approximately 25% of PE cases are intermediate-risk, with mortality rates between 5-25%. Management strategies for intermediate-risk PE remain inconsistent. This study compares clinical outcomes of intermediate high-risk PE patients receiving anticoagulation therapy alone (ACT) versus those receiving systemic reperfusion therapy (RT) plus anticoagulation. Methods: This retrospective study at AdventHealth hospitals in Central Florida included adult PE patients with right ventricular strain diagnosed from January 1, 2019, to December 31, 2020. Exclusions were patients needing vasopressors or invasive ventilatory support at admission and those treated primarily with mechanical thrombectomy or catheter-directed thrombolytic therapy. Patients were divided into two groups: standard ACT and systemic RT plus ACT. Demographics, comorbidities, lab values, treatments, and outcomes were collected and compared. Results: Of 641 patients, 461 met inclusion criteria, with a median age of 65 and median BMI of 31.2. The cohort included 216 high-risk intermediate PE patients, with 52 patients receiving the thrombolytic therapy and 164 receiving the anticoagulation therapy. There was no significant difference in in-hospital (p = 0.450) or 30-day mortality rates (p = 0.591) between the two treatment groups. Secondary outcomes, including major bleeding (p = 0.569), use of vasopressors (p = 0.969), mechanical ventilation (p = 0.804), CPR (p = 0.450), or transfusion, also showed no significant difference. Notably, 23.2% of patients in the anticoagulation-only group required secondary thrombolytic therapy within 24 hours. Patients receiving systemic RT were younger (p = 0.017) and had a higher BMI (p = 0.012). Discussion: This study supports guidelines advising against routine use of RT for intermediate high-risk PE unless as rescue therapy. No mortality rate reduction or secondary outcome benefits were observed, highlighting the need for consistent management protocols and further research on therapeutic approaches for intermediate high-risk PE.