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Background: Clinical picture and outcome of incidental pulmonary embolism (iPE) compared to symptomatic pulmonary embolism (sPE) remain unclear. Methods: Demographics, recurrent venous thromboembolism (VTE), mortality, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) were compared between iPE and sPE patients who were followed prospectively at Mayo Thrombophilia Clinic (March 1, 2013 to August 1, 2020). Results: Out of 3576 VTE patients, 1417 (39.6%) had PE: 562 (39.7%) iPE and 855 sPE. Patients with cancer were more likely to have iPE (400 iPE vs. 314 sPE) compared to those without cancer (162 iPE vs. 541 sPE). VTE recurrence rate (all per 100 person‐years) was similar in all iPE and sPE patients (3.34 vs. 3.68, p =.50), with cancer (4.16 vs. 4.89, p =.370), and without cancer patients (0.89 vs. 2.80, p =.25). Higher mortality observed in all patients with iPE compared to sPE (46.45 vs. 23.47, p <.001) and with cancer (56.41 vs. 45.77, p =.03) became not significant after adjustment for age, antiplatelet therapy, metastases, and cancer location. Noncancer iPE patients had higher mortality (15.95 vs. 7.18, p =.006) even after adjustment (p =.05). The major bleeding rate was also higher in all patients iPE compared to sPE (7.10 vs. 3.68, p =.03), but not after adjustment (p =.974); higher major bleeding rate in noncancer patients (6.49 vs. 1.25, p =.007) remained significant after adjustment (.02). CRNMB rate was similar to iPE and sPE patients. Conclusion: iPE represents a more serious clinical condition compared to sPE as indicated by the higher mortality and major bleeding but these differences reflect underlying comorbidities rather than the seriousness of the embolic event. [ABSTRACT FROM AUTHOR]

Cancer therapy and progress in quality of imaging technologies for cancer surveillance and staging are in cause for the increase incidence of smaller incidental pulmonary embolism (PE). The clinical significance of incidental subsegmental pulmonary embolism (SSPE) is hard to define, balancing between possible false positive result, hypercoagulability signal, and truly venous thromboembolism (VTE) event. Evidence for optimal management of such findings are largely extrapolated from symptomatic SSPE in non-cancer patients and from symptomatic, more proximal PE in cancer patients. Current practice guidelines vary but some suggest withholding anticoagulation in selected patients. However, most SSPEs, incidental or not, should be treated as any other cancer-associated PE due to likely similar prognosis. Choice and duration of anticoagulation are extended from existing knowledge on more proximal PE. • Incidental subsegmental pulmonary embolism is a frequent finding in cancer patients • Clinical relevance of incidental SSPE in cancer is uncertain, but prognosis might be similar to symptomatic more central PE • Confirmed incidental subsegmental pulmonary embolism should be treated as any other pulmonary embolism [ABSTRACT FROM AUTHOR]

Purpose: The EPIPHANY index was developed to classify cancer associated pulmonary embolism (PE) into different risk categories using decision tree modeling. In this study, we tried to externally validate this index in a distinct group of patients solely composed of incidental PE (IPE).Methods: A retrospective study of patients diagnosed with IPE in two Emergency Departments in the USA and South Korea from 2013 to 2014 was performed. The primary outcome was the occurrence of a serious medical complication within 15 days of presentation to ED. Thirty-day complication was the secondary outcome. Cumulative hazard curves for each prognostic category were drawn to show the change in hazards over time.Results: A total of 258 patients with IPE were included (193 from MD Anderson Cancer Center and 65 from Asan Medical Center). Serious complication within 15 days occurred in 23 (8.9%) patients. The risk of overall 15-day and 30-day serious complications increased with each category (low, intermediate, and high risk: 3.4, 8.9, and 23.8%, P = 0.033; 6.9, 9.5, and 33.3%, P = 0.011). Cumulative hazard curves for each prognostic category were drawn and the survival functions factored by prognostic categories were significantly different over 15 days (P = 0.015) and 30 days (P = 0.001).Conclusions: Our study suggests the EPIPHANY index could be a useful adjunct tool in risk stratification of cancer patients with IPE. [ABSTRACT FROM AUTHOR]

Background: Most patients with pulmonary embolism (PE) spend 5–7 days in hospital even though only 4.5% will develop serious complications during this time. In particular, the group of patients with incidentally diagnosed PE (i-PE) includes many patients with low risk features potentially ideal for outpatient management; however the evidence for their optimal management is lacking hence relative practices may vary considerably. We describe the development process, components, links and function of a nurse-led service for the management of patients with i-PE, developed in accordance to the UK Medical Research Council complex intervention guidance. Methods: Phase 0 (Theoretical underpinning): The Pulmonary Embolism Severity Index (PESI) was selected for patient risk assessment and the American Society of Clinical Oncology (ASCO) guideline for the management of PE in cancer patients (2007) was selected as quality measure. Historical registry and audit data from our centre regarding i-PE incidence and management for the period between 2006 and 2009 illustrating the then current practices were reviewed. Phase 1 (Modelling): Modelling of the pathway included the following: a) Identification of training needs, planning and implementation of training schemes and development of transferable competencies and training materials. b) Mapping patient pathways and flow and c) Production of key documentation and Standard Operating Procedures for the delivery of the service. Results: Phase 2 (Implementation and testing of the intervention): During the initial 12 months of implementation, remedial action was taken to address identified deficiencies regarding patient referral to the pathway, compliance with treatment protocol, patient follow up, selection challenges from the use of PESI in cancer patients and challenges regarding the “first-pass” identification of i-PE. Conclusion: We have developed and piloted a complex intervention to manage cancer patients with incidental PE in an outpatient setting. Adherence to evidence- based care, improvement of communication between professionals and patients, and improved quality of data is demonstrated. [ABSTRACT FROM AUTHOR]