Catheter-Directed Therapies may be Safer option for Frail elderly Patients with Pulmonary Embolism

The safety of reperfusion therapies, particularly catheter-directed therapies, for elderly and frail patients with pulmonary embolism (PE) is a subject of paramount concern. In light of recent findings, it has become increasingly evident that these innovative approaches offer a more secure alternative to classical reperfusion therapies in the management of PE among vulnerable populations.

The study was published in the EuroIntervention. 

Reperfusion therapy, a vital intervention for patients with pulmonary embolism (PE), presents unique challenges when applied to elderly and frail individuals. In cases where systemic thrombolysis (ST) is contraindicated or has proven ineffective, catheter-directed therapies offer a promising alternative. However, the safety and efficacy of these innovative approaches in specific vulnerable populations have remained largely unexplored. Hence researchers conducted a study to assess the safety of reperfusion therapies in elderly and frail patients in the real world.

The research leveraged data from the US Nationwide Inpatient Sample collected between 2016 and 2020. The study focused on hospitalizations of patients aged 65 and above who were diagnosed with PE. Among this cohort, a subgroup classified as frail was identified using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. The primary objective was to assess the utilization of reperfusion therapies, including systemic thrombolysis (ST), catheter-directed thrombolysis (CDT), catheter-based thrombectomy (CBT), and surgical embolectomy (SE), and their associated safety outcomes, specifically overall and major bleeding events.

Key findings: 

• The study encompassed 9,80,245 hospitalizations of patients aged 65 and above with PE, with 28.0% classified as frail.
• Among this population, reperfusion therapies were employed in 4.9% of cases, rising to 17.6% among patients with high-risk PE.
• Notably, while ST utilization remained consistent, the use of catheter-directed therapies surged from 1.7% in 2016 to 3.2% in 2020.
• Comparing the safety outcomes of reperfusion therapies, it was observed that CDT, when compared to ST, was linked to a reduction in major bleeding events (5.8% vs. 12.2%, odds ratio [OR] 0.58, 95% confidence interval [CI]: 0.49-0.70).
• Importantly, these findings held true for frail patients as well.
• In addition, CBT, as opposed to SE, was associated with a decreased incidence of major bleeding (11.0% vs. 22.4%, OR 0.63, 95% CI: 0.43-0.91), although this advantage was not evident among frail patients.
• These differences were particularly significant among patients with non-high-risk PE. Similar trends were observed for overall bleeding events.

Thus, this study provides compelling evidence that catheter-directed therapies may represent a safer alternative to conventional reperfusion therapies for elderly and frail patients in need of reperfusion treatment for pulmonary embolism. These findings have significant implications for improving the safety and efficacy of PE management in these vulnerable populations, offering hope for better outcomes and enhanced patient care.

Further reading: A nationwide analysis of reperfusion therapies for pulmonary embolism in older patients with frailty. DOI: 10.4244/EIJ-D-23-00399