Early DOAC therapy after invasive acute pulmonary embolism therapy: fast track PE?

Introduction: Percutaneous invasive therapies, including catheter-directed thrombolysis (CDT) and mechanical thrombectomy (MT), have emerged as treatment options for high-risk and selected intermediate high-risk PE. Patients undergoing these procedures were excluded from the landmark DOAC trials, so the safety and efficacy of early DOAC therapy in this setting remains unexplored. We aimed to access these outcomes in a cohort of invasively treated PE patients. Methods: Retrospective cohort study analysing PE patients who underwent CDT and/or MT at a tertiary centre from 2020 to 2024. Patients were grouped based on the timing of DOAC initiation: within 24 hours (group 1), between 24-48 hours (group 2), and after 48 hours (group 3). The primary safety outcome was major bleeding events according to International Society on Thrombosis and Haemostasis (ISTH) criteria, and the primary effectiveness outcome was venous thromboembolism recurrence. Results: A total of 74 patients (mean age 59±16 years; 43% male) underwent percutaneous interventions for PE, 47% with MT, 26% with CDT using recombinant tissue-type plasminogen activator (rt-PA), and 27% with both. All patients received unfractionated heparin post-procedure. A total of 14 patients initiated DOAC (apixaban or rivaroxaban) within 24 hours, and 11 additional patients within 48 hours-Figure 1. No significant baseline differences were observed between groups, except for higher admission haemoglobin in Group 1 and male gender in group 2 (Table 1). However, group 3 had more patients with syncope or cardiac arrest, and higher PESI scores and NTproBNP levels. Systemic rt-PA was administered in 1 patient in group 2 and 5 patients in group 3 (p=0.47). The type of invasive PE therapy was comparable across groups. The low number of bleeding complications (9 major bleeding events), occurred mostly in group 3, and all during index hospitalization. At 30-days follow-up, no venous thrombosis recurrence had occurred. Patients on group 1 experienced a significantly shorter hospital stay compared to those on group 3 (5 days [3-7] vs 10 days [6-14], p<0.001). No differences were noted between groups 1 and 2. On multivariate analysis, female sex, higher systolic blood pressure, and the absence of a saddle thrombus were identified as predictors of an early switch to DOAC within the first 48 hours (Table 2). Conclusion: Early initiation of DOACs following MT and/or CDT for acute PE appears to be a safe approach. Moreover, no signs of lower efficacy were raised by this analysis, and is additionally associated with a shorter hospital stay. Patient selection criteria for this treatment strategy should be further analysed, to allow shorter hospitalizations and improve patient outcomes.