April 28, 2021

Study Evaluates the Impact of PERT Consultations on Outcomes During the COVID-19 Pandemic

April 28, 2021—In a single-center study evaluating pulmonary embolism response team (PERT) activation, treatment, and in-hospital outcomes during the COVID-19 pandemic, Finn et al found that PERT utilization was almost threefold higher during the pandemic compared with historical controls, while rates of in-hospital mortality and moderate-to-severe bleeding were not significantly different. The results of the study were published online in Vascular Medicine.

Key Findings

PERT consultations increased almost threefold during the COVID-19 pandemic as compared with historical controls.
PERT-guided invasive therapy was offered less frequently during COVID-19.
In-hospital mortality and GUSTO scale moderate-to-severe bleeding rates were numerically but not significantly higher during COVID-19.

PERT consultation requests from March 1, 2020 through April 30, 2020 during the peak COVID-19 admission period were examined and compared with historical controls during the same period in 2019. Data were extracted from the electronic medical record. Bleeding outcomes were measured using the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) and Bleeding Academic Research Consortium (BARC) scales. Invasive therapy was defined as catheter-based strategies performed in the cardiac cath lab, operating room, or interventional radiology suite and included mechanical thrombectomy and catheter-directed lysis. The primary study endpoints were inpatient mortality and GUSTO moderate-to-severe bleeding.

There were 100 total consults included in the study, 26 from March 2019 to April 2019 and 74 from March 2020 to April 2020. PERT consults were 2.8 times more common during the pandemic than in 2019. The rate of intensive care unit admission was similar between groups; however, patients were significantly more likely to require mechanical ventilation or vasoactive medication during the pandemic compared with controls (47.3% vs 15.4%; P = .04 and 50% vs 19.2%; P = .006, respectively).

During COVID-19, invasive therapy was used less often (5.5% vs 23.1% for controls; P = .02). The use of systemic fibrinolytic therapy was significantly increased in patients with COVID-19 (13.5% vs 3.9%; P = .03). In-hospital mortality and moderate-to-severe bleeding were nonsignificantly higher in patients receiving PERT consultations during COVID-19 as compared with historical controls (14.9% vs 3.9%; P = .18 and 35.1% vs 19.2%; P = .13). There were no differences in BARC scale major bleeding between groups, but there was a higher rate of BARC scale minor bleeding in COVID-19 era patients (91.9% vs 57.7%; P < .0001).

COVID-19–positive status (odds ratio [OR], 9.1; 95% CI, 1.44-57.51; P = .02), age (OR, 0.89; 95% CI, 0.82-0.97; P = .008), and body mass index (OR, 0.88; 95% CI, 0.80-0.97; P = .01) were associated with in-hospital mortality on multivariable logistic regression analysis. However, traditional pulmonary embolism (PE) risk factors (severity of PE, categorical biomarker elevation, degree of right ventricular enlargement) were not statistically significant, noted the investigators.

ENDOVASCULAR TODAY ASKS….

Investigator Sanjum S. Sethi, MD, with Columbia University Medical Center in New York, was asked to comment on the study results:

Based on the study, what is your biggest takeaway regarding the utility of PERTs, both during a pandemic and outside of the COVID-19 setting?

Since PERTs have been adopted by more institutions over the last decade, clinicians are recognizing the value in providing a multidisciplinary approach to decision-making in complex patients. COVID-19 patients with known or suspected PE are usually critically ill and complex, which is one of the reasons we saw a surge in consults during the pandemic wave last Spring. Our study highlights how real-world decision-making may change depending upon the clinical situation at hand. For instance, we certainly saw a shift in the use of fibrinolytic therapy over invasive therapy for a whole variety of reasons, including but not limited to exposure risks. One of the consequences of this shift was more bleeding events. Having a team-based approach where the various clinical specialties involved can weigh these risks and benefits and subsequently explain them to the patient (or surrogate decision-makers) is a powerful mechanism for hopefully achieving comprehensive, thoughtful, and compassionate care for our patients. The applications for this approach extend beyond a pandemic scenario as illustrated by structural heart valve teams, critical limb ischemia teams, and oncology tumor boards.

In the discussion, you noted that > 30% of patients in the COVID-19 cohort remained inpatients at the end of the study. Do you expect to perform further analysis to capture any additional outcome data, and is there potential for the outcomes in this group to affect the overall findings?

As the readers are likely aware, critically ill COVID-19 patients often have protracted intensive care unit stays with significant morbidity and rehabilitation needs. We are continuing to gather data on the long-term impact in this patient population. It is conceivable that further study would lead to a mortality difference between groups; however, this would be pure speculation. The fundamental purpose of this analysis was to characterize the nature of the PERT consult surge during the COVID-19 pandemic.

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