A67-21 Clinical Characteristics and Outcomes of Cardiac Arrest Due to Confirmed or Suspected Fulminant Pulmonary Embolism Treated With Tenecteplase

Rational Pulmonary embolism (PE) causes 2-9% of OHCA and 5-6% of IHCA. Despite known treatments, untreated PE with cardiac arrest (CA) has a mortality approaching 95%1. This study aimed to evaluate outcomes in the use of tenecteplase in PE-CA. To our knowledge, this represents the largest retrospective study of tenecteplase use in PE-related CA. Methods We conducted a retrospective observational study using a contiguous sample of 55 adults. Inclusion criteria consisted of patients > 18 years old who experienced CA in the setting of suspected or confirmed PE and received tenecteplase at our institution between 2014 and 2024. Outcomes of interest included time to tenecteplase administration, return of spontaneous circulation (ROSC), major bleeding events, use of advanced PE therapy (catheter directed therapy, mechanical thrombectomy, or extracorporeal membrane oxygenation [ECMO]), 24-hour survival, survival to discharge. Results Mean age was 62.5 years, 64% male. 67% experienced IHCA and 33% OHCA. The mean duration of CPR was 29 minutes. 91% received a full dose of tenecteplase with 76% achieving ROSC. Tenecteplase was administered during CPR in 49% of cases and 39% had ongoing CPR for >15 minutes post-administration. 58% of patients were receiving concomitant anticoagulation. Major bleeding occurred in 25.5% (20% extra-cranial, 1.8% intra-cranial, and 1.8% combined). Overall survival to hospital discharge was 24% (11% for OHCA) despite 49% 24-hour survival post-CA. Notably, all patients (5/55=9%) who received early advanced PE therapy after CA and systemic thrombolysis survived to discharge. Early use of advanced PE therapy was associated with a 2.5-fold higher likelihood of survival in fulminant PE with CA (RR 2.5, p-value 0.01, 95% CI 1.4-4.5). Conclusion The discrepancy between 24 hours survival and overall mortality, paired with the improved survival in patients receiving advanced PE therapy, introduces an opportunity for further investigation into post ROSC care in fulminant PE. Major bleeding occurred in approximately one quarter of patients, though there were very few intra-cranial events, which could suggest perceived risk of ICH is higher than demonstrated. Early implementation of advanced PE therapies was strongly associated with improved survival to discharge. This retrospective analysis supports the role of tenecteplace as a viable fibrinolytic agent in CA suspected to be from PE and suggests a favorable adverse event profile. While further study is needed, we recommend the early use of tenecteplace administration in fulminant PE, prolonged CPR post-tenecteplace administration, and early escalation to advanced therapy in selected patients.