The management of pulmonary embolism

Acute pulmonary embolism (PE) is a common problem with high morbidity and a 30-d mortality rate of 15–20%. Because of the scope and severity of the problem, the accurate diagnosis and management of acute PE is crucial. Echocardiography has increasing applications in the diagnosis, the risk assessment, and the management of PE. As a first-line tool, echocardiography allows for the preliminary differentiation of major lifethreatening cardiovascular complications. Additionally, bedside echocardiography affords the opportunity to establish a prompt diagnosis and to identify patients with high-risk features, thus identifying a subset of patients that may benefit from more aggressive therapy, such as thrombolytic therapy. The use of echocardiography in the evaluation and management of PE is increasingly common as demonstrated in two recent registries, in which approx 50–75% of patients with PE underwent echocardiography.

Acute pulmonary embolism (PE) remains one of the leading causes of mortality and morbidity in cardiovascular setting. Despite much information about clinical aspects and recommendations or clinical guidelines is available from literature, few data exist about the management of PE in real world of internal medicine scenario. Therefore the aim of the present study was to report on characteristics and management of PE patients admitted in this setting. TUSCAN-PE study was a multicenter, observational, retrospective, cohort study aimed to analyze data of PE patients admitted in Internal Medicine wards of Tuscany. Each center was invited to submit anonymously data of at least ten patients consecutively discharged for acute PE in 2012. Data were referred to demographic, clinical, instrumental, prognostic and therapeutic characteristics. A total of 452 patients from 28 Tuscan centers (60.2% F), with mean age 76.01±12.34 years, were enrolled. A total of 87% of patients was admitted from Emergency Department, but only 65.2% of patients with diagnosis of PE. Around one third of diagnoses of PE was performed by internists. In 14.8% of diagnoses was incidental. In 86% of patients, diagnosis was performed by computer tomography pulmonary angiography. Overall mortality was 9.5%, 5.75% being PE-related. Main risk factors enclosed recent respiratory tract infections (55.3%), immobility (42.25%), recent hospital admissions (33.6%) and cancer (30.3%). In 65.8% of patients, PE was associated with deep vein thrombosis. 16.6% of patients had a shock index ≥1 and 84.75% simplified pulmonary embolism severity index (PESI) score ≥1. A number of 51.5% of patients presented echocardiographic right heart dysfunction, 50.6% and 55.9% of patients presented increased values of troponins and natriuretic peptides, respectively. The following percentage, 6.5%, 71.1% and 22.4%, were defined as high, intermediate and low risk according to the European Society of Cardiology (ESC) criteria, respectively. Antithrombotic treatment was started in Internal Medicine wards in 60.6% of patients. 4.9% of patients were treated with systemic thrombolysis, 15.1% with intravenous unfractionated heparin, whereas low molecular weight heparins and fondaparinux were performed in 39.2% and 39.8% of patients, respectively. Vitamin K antagonists were prescribed in 52.1% of patients at hospital discharge. Fatal and non-fatal major bleedings occurred in 1.7% of patients. TUSCAN-PE study contributes to the knowledge of real life management of acute PE in the Internal Medicine setting.

MULTIORGAN FAILURE AND SEVERE THROMBOCYTOPENIA FROM MASSIVE PULMONARY EMBOLISM WITH A CHALLENGING MANAGEMENT

<h3>Introduction</h3> Venous thromboembolism risk is higher in the puerperium and pulmonary embolism (PE) is a leading cause of maternal death. IV unfractionated heparin (UFH) is considered first line treatment but favourable outcomes following thrombolysis have been recorded. The ESC guidelines recommend the use of a multidisciplinary team to plan the management of these women.¹ <h3>Aim</h3> To review the management and outcomes of pregnant and post-partum women admitted to a tertiary referral centre with intermediate-high risk (IHR) and high risk (HR). <h3>Method</h3> A retrospective case notes review of pregnant and post-partum patients admitted with IHR and HR PEs between 2014 and 2019. All patients were reviewed by PELT (comprising specialists in respiratory, haematology, interventional radiology and obstetric medicine in conjunction with imaging, PESI score, troponin and NT-proBNP). All treatment decisions were made in conjunction with informed patient consent. <h3>Results</h3> Seven patients with IHR or HR PE (6 pregnant and 1 post-partum) were admitted. Of these, 4 were transferred from other hospitals. Three of the patients (gestations 10/40, 22/40 and 37+4/40) received UFH alone, two (gestations 31/40 and 38/40) were treated with catheter directed thrombolysis (CDT) and one patient (gestation 22/40) received half-dose systemic thrombolysis after haemodynamic collapse. One patient presented 4 weeks post-partum and received CDT. There were no major and only one minor bleeding complications. All patients clinically improved, with resolution of echocardiographic changes and improvement in cardiac biomarkers. There was no maternal mortality. One woman who initially presented with vaginal bleeding at 10 weeks, was treated with UFH and went on to suffer a miscarriage. All other patients went on to complete pregnancy successfully. One patient who underwent CDT had an elective caesarean section during her inpatient stay. <h3>Conclusion</h3> The management of PEs in pregnancy is difficult and treatment decisions should be patient specific. Thrombolysis and CDT give good outcomes in carefully selected patients. A PELT team with the input of Obstetric Medicine specialists is invaluable in making these decisions. <h3>Reference</h3> Konstantinides, <i>et al</i>. 2019. ‘ESC Guidelines for the diagnosis and management of the acute pulmonary embolism developed in collaboration with the ERS’. <i>ERJ</i>. Vol 56Issue 2.

Characteristics and outcomes of COVID-19-associated pulmonary embolism

Venous thromboembolism (VTE), the combined syndromes of deep vein thrombosis (DVT) and pulmonary embolism (PE), is currently the third most frequent acute cardiovascular syndrome globally behind myocardial infarction and stroke. PE carries substantial mortality. In the past decade, we have seen a remarkable improvement in new diagnostic tools as well as advances in therapeutic options to manage patients with PE. Still, even with recently updated society guidelines, the management of intermediate and high-risk PE requires clinician expertise and judgment. To aid healthcare providers caring for patients with acute PE, we have developed a novel, comprehensive yet straightforward, pathway for the management of patients with PE. We believe this pathway can be used in many healthcare systems around the globe. Our pathway for the diagnosis and management of PE is divided into 3 steps: the diagnosis of PE, the acute management of patients with PE, and recommendations for chronic management. The pathway requires classification of the PE by the risk of mortality and thus leads to the appropriate intensity of initial care, intervention, and monitoring. The Pulmonary Embolism Response Team (PERT) is a multispecialty team designed to guide the decision-making for the individual patient with intermediate-high or high-risk PE. The PERT team brings together specialists from different disciplines. The team convenes in real time via a platform such as WhatsApp or text messages to communicate clinical data, discuss the options, and provide consensus for a course of management. The success of this pathway to manage PE depends heavily on developing a collaborative group of specialists dedicated to provide care at each stage to patients with PE.

A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both

Questioning the use of an age‐adjusted D‐dimer threshold to exclude venous thromboembolism: comment

BackgroundExisting evidence indicates Black patients have higher incidence of pulmonary embolism (PE) and PE‐related mortality compared with other races/ethnicities, yet disparities in presenting severity and treatment remain incompletely understood.Methods and ResultsWe retrospectively queried a multihospital healthcare system for all hospitalizations for acute PE (2012–2019). Of 10 329 hospitalizations, 8743 met inclusion criteria. Black patients (14.3%) were significantly younger (54.6±17.8 versus 63.1±16.6 years; P<0.001) and more female (56.1% versus 51.6%; P=0.003) compared with White patients. Using ordinal regression, Black race was significantly associated with higher PE severity after matching 1:3 on age and sex (1210:3264; odds ratio [OR], 1.08; 95% CI, 1.03–1.14), adjusting for clinical (OR, 1.13; 95% CI, 1.01–1.27), and socioeconomic (OR, 1.05; 95% CI, 1.05–1.35) characteristics. Among intermediate and high‐severity PE, Black race was associated with a decreased risk of intervention controlling for the competing risk of mortality and censoring on hospital discharge. This effect was modified by PE severity (P value <0.001), with a lower and higher risk of intervention for intermediate and high‐severity PE, respectively. Race was not associated with in‐hospital mortality (OR, 0.84; 95% CI, 0.69–1.02).ConclusionsBlack patients hospitalized with PE are younger with a higher severity of disease compared with White patients. Although Black patients are less likely to receive an intervention overall, this differed depending on PE severity with higher risk of intervention only for life‐threatening PE. This suggests nuanced racial disparities in management of PE and highlights the complexities of healthcare inequalities.

Bolus and Accelerated Thrombolysis: Experimental Observations and Clinical Management of Myocardial Infarction and Pulmonary Embolism

The use and scope of thrombolytic therapy in the management of pulmonary embolism (PE) continues to evolve. The results of small studies suggest that thrombolytic therapy might have an impact on survival in massive PE with cardiogenic shock; however, no large studies to further this notion exist. Furthermore, the expanded application of thrombolytic therapy to patients with PE and right ventricular dysfunction (RVD) but without overt hemodynamic collapse remains controversial. We report successful use of the thrombolytic agent tissue plasminogen activator (tPA) in the management of life-threatening PE with RVD without overt cardiovascular collapse. We present evidence for the meritorious use of thrombolytic therapy in this category of PE patients. We believe that a broadened application of thrombolytic therapy to patients with PE and RVD but without cardiogenic shock, especially in younger patients, is beneficial and worth the risk.

Management of pulmonary embolism in postoperative patients

Acute pulmonary embolism is the third leading cause of cardiovascular death, with most pulmonary embolism-related mortality associated with acute right ventricular failure. Although there has recently been increased clinical attention to acute pulmonary embolism with the adoption of multidisciplinary pulmonary embolism response teams, mortality of patients with pulmonary embolism who present with hemodynamic compromise remains high when current guideline-directed therapy is followed. Because historical data and practice patterns affect current consensus treatment recommendations, surgical embolectomy has largely been relegated to patients who have contraindications to other treatments or when other treatment modalities fail. Despite a selection bias toward patients with greater illness, a growing body of literature describes the safety and efficacy of the surgical management of acute pulmonary embolism, especially in the hemodynamically compromised population. The purpose of this document is to describe modern techniques, strategies, and outcomes of surgical embolectomy and venoarterial extracorporeal membrane oxygenation and to suggest strategies to better understand the role of surgery in the management of pulmonary embolisms.

To describe the use of inhaled aerosolized prostacyclin (IAP) in a patient with life-threatening pulmonary hypertension secondary to pulmonary embolism and to discuss the possible use of inhaled prostacyclin in the management of pulmonary embolism. Case report. Intensive care unit of a university teaching hospital. One patient with severe pulmonary hypertension secondary to acute-on-chronic pulmonary embolism. Conventional medical management of massive pulmonary embolism and inhaled aerosolized prostacyclin (IAP). Description of clinical course, haemodynamic data and gas exchange data. We describe a patient with massive pulmonary embolism for whom the addition of IAP to his therapy appeared to result in a transient improvement in pulmonary haemodynamics and gas exchange.

Ambulatory management of pulmonary embolism: a pragmatic evaluation.