Association of Time-To-Anticoagulation (TTAC) With Right Ventricular(RV) Function on Outpatient Follow-up Among Patients With Acute Pulmonary Embolism (PE) Managed by the Pulmonary Embolism Response Team (PERT): A Retrospective Study

Abstract Rationale: PE is the third most common acute vascular disease worldwide. While the notion of “time is tissue” is established for ischemic stroke and myocardial infarction, the impact of TTAC on outcomes after acute PE is not defined. We examined the association between TTAC and echocardiographic parameters of RV function on outpatient follow-up for patients with acute PE managed by PERT. Methods: A retrospective chart review of patients with acute PE, managed by PERT at one of three urban teaching hospitals in the Mount Sinai Health System from January 2021 to September 2023, was performed. TTAC was defined as time from diagnosis of acute PE to time of initiation of systemic anticoagulation. A propensity score-matched analysis was performed using the MatchIt package for R with optimal full matching specification. Regression models were constructed in the propensity score matched sample to assess associations between TTAC and RV echocardiographic parameters. Results:123 patients were amalyzed. The median age was 64.4(IQR: 52.5-75) years and 43.1%(n=53) were female. Median PESI score was 87(IQR: 69-99.5). Based on ESC risk stratification, 1(0.8%), 25(20.3%), 76(61.8%) and 21(17.1%) had low, intermediate low, intermediate high and high-risk acute PE. ART(advanced reperfusion therapies) were administered to 40(32.5%) patients including catheter directed embolectomy (21,17.1%), catheter directed thrombolysis(11,8.9%) and surgical embolectomy(11,8.9%). Median TTAC for the entire cohort was 2.0(IQR: 0.9-4.3) hours. After splitting the cohort into quartiles of TTAC, propensity score matching was performed on age, BMI, PESI, ESC risk group, composite PE shock score and receipt of ART. Propensity score-matched patients in the first quartile of TTAC(</= 57 minutes) had greater improvements in tricuspid regurgitant(TR) jet maximum velocity(marginal mean: -1.249; p=0.003) and pulmonary artery systolic pressure(PASP; marginal mean: -7.902; p=0.005), at median follow-up of 26 weeks, as compared to patients in the fourth quartile of TTAC(>/= 4.3 hours/257 minutes). Sensitivity analyses were performed by dichotomizing echocardiographic parameters into normal and abnormal and proportion of normalization was compared between first and fourth quartiles with respect to TTAC. A statistically significant trend was noted for normalization of TR jet maximum velocity(marginal odds ratio: 3.553; p<0.001) and PASP(marginal odds ratio: 2.409; p<0.001) among patients with TTAC in the first quartile as compared to those with TTAC in the fourth quartile. Conclusion: Among PERT managed patients with acute PE, shorter TTAC was significantly associated with greater improvements in TR jet maximum velocity and PASP on follow-up echocardiography as compared to patients with longer TTAC.