Barriers to guideline implementation in intermediate- and high-risk Pulmonary Embolism: insights from a real-world cohort study.

BACKGROUND

Pulmonary embolism (PE) presents significant challenges due to its wide clinical spectrum, associated right ventricular failure, and high mortality rates. Despite guideline recommendations for systemic thrombolysis in high-risk PE, its implementation remains suboptimal due to safety concerns. This study investigates barriers to guideline implementation in treating intermediate- and high-risk PE and assesses catheter-based thrombectomy (CBT) as an alternative treatment.

METHODS

A single centre retrospective cohort study analyzed medical records of all PE-diagnoses between January 2022 and June 2023 . Patients with central, lobar, or segmental PE and Pulmonary Embolism Severity Index scores of III - V were included. A subgroup of patients received CBT. Data on patient characteristics, treatment, outcomes, and eligibility for CBT were collected.

RESULTS

Of the 124 intermediate- and high-risk patients, thrombolysis was administered to only 17% of high-risk patients. Within the conventional treatment group, barriers to thrombolysis included contra-indications in 72% of intermediate-risk and 80% of high-risk patients, leaving a significant number eligible for CBT. Additionally, 20% of high-risk PE patients who did not received thrombolysis had no contra-indications and should have been treated with thrombolysis. In-hospital mortality was 50% among high-risk patients. Eleven patients received CBT, with no mortality at 30 days.

CONCLUSIONS

Guideline-recommended thrombolysis is underutilized in high-risk PE, due to safety concerns and contra-indications. CBT demonstrates a promising alternative with a favourable safety profile and low mortality rates, highlighting the need for prospective studies. Multidisciplinary approaches, such as Pulmonary Embolism Response Teams, may help to standardize care and to improve outcomes.