The management of pulmonary embolism

Management of pulmonary embolism

Counterpoint: Should Systemic Lytic Therapy Be Used for Submassive Pulmonary Embolism? No

ABSTRACTIntroduction: Acute pulmonary embolism (PE) is a relatively common cardiopulmonary emergency that is a major cause of hospitalization and morbidity and is the primary cause of mortality associated with venous thromboembolism (VTE). During the last decade, one of the biggest changes in the management of PE has been the approval of four non-vitamin K antagonist oral anticoagulants (NOACs; apixaban, dabigatran, edoxaban and rivaroxaban) for the treatment of PE and deep vein thrombosis and secondary prevention of VTE.Areas covered: This article reviews the evolving management of PE in the NOAC era and addresses three fundamental questions: who should receive NOACs over conventional heparin/vitamin K antagonist regimens for the treatment of acute PE; should patients be treated as inpatients or outpatients; and how long should patients be treated to reduce the risk of recurrence?Expert commentary: The management of PE is changing. NOACs provide new anticoagulant treatment options for patients with PE, based on Phase III clinical study results. The consistent efficacy and safety profile of NOACs across many PE patient subgroups, including the elderly, fragile patients, those with active cancer and high-risk (right ventricular dysfunction) patients, suggests NOAC use will increase among these patients.

Risk Stratification for Acute Pulmonary Embolism

There is some uncertainty about the management of pulmonary embolism in nonagenarians. Immobility plays an important role in the pathogenesis of venous thromboembolism in the elderly. Of 858 nonagenarians with acute venous thromboembolism enrolled in Registro Informatizado de la Enfermedad TromboEmbolica venosa registry, 41% had recent immobility and only 7.7% had recent surgery. Comorbidity is common: 19% of patients had chronic heart failure, 9.8% chronic lung disease, 14% cancer, and 63% had abnormal creatinine levels. Most (92%) of the patients were initially treated with low-molecular-weight heparin and then 46% switched to antivitamin K drugs. During follow-up, the proportion of patients who developed recurrent venous thromboembolism (4.9%) or major bleeding complications (6.2%) was similar, but the 5.9% of fatal pulmonary embolisms by far exceeded the 2.2% of fatal bleeding events. The most common clinical symptoms are isolated dyspnea and syncope, and presentation as pulmonary infarction (with hemoptysis and pleuritic chest pain) is rare. In patients aged at least 90 years presenting with acute pulmonary embolism, the incidence of fatal pulmonary embolism by far outweighs the incidence of fatal bleeding, and pulmonary embolism is the most common cause of death. Thus, there seems to be more reason to be concerned about fatal pulmonary embolism than about bleeding in elderly patients presenting with pulmonary embolism.

IMPORTANCE OF POINT-OF-CARE ULTRASONOGRAPHY IN THE EVALUATION OF UNDIFFERENTIATED SHOCK

Over the last two decades multiple interventions have been implemented to support critical care survivors, each with limited success in improving quality of life and clinical outcomes. There has been limited evaluation of longitudinal critical illness recovery care, including any corresponding impact on the healthcare system or clinicians. The objective of this analysis was to explore the experience of clinicians reconnecting with survivors of critical illness and the subsequent impact that this reconnection was perceived to have within the healthcare system. We conducted an international qualitative investigation using in-depth semi-structured interviews with clinicians from varied settings, including the UK National Health Service, USA Veteran Affairs, and USA Safety Net Hospitals. Clinicians represented different professional disciplines, specialities, and experience. Interviews were analysed using Framework Analysis. Nineteen clinicians were interviewed. Of those interviewed, 16 (84%) were female, and the majority worked in critical care settings (n=10, 53%). In total, 16 healthcare system settings were represented across the interviews. Following the identification of how reconnection with survivors was operationalised, six themes were identified, and categorised into two domains. The first domain was the Impact of reconnection for clinicians and included: mitigation against emotional exhaustion; workplace meaning; and value placed on staff. The second domain was the Impact on the critical care system and care delivery and included humanisation of care delivery; richer insights to underpin decision-making; and the provision of data to drive improvements in care. This multi-centre international investigation suggests that there are potentially benefits for clinician wellbeing as well as the delivery of care within the critical care setting from reconnection between survivors of critical illness and clinicians. This research has explored the experience of reconnection between critical care survivors and clinicians from a clinician perspective. It has shown potential benefits for clinician wellbeing as well as the delivery of care within the critical care setting. Reconnection and how it could be incorporated into critical care services should be considered in future research.

Background/Objectives: Pulmonary embolism (PE) is the third leading cause of cardiovascular mortality and presents significant diagnostic and therapeutic challenges in the emergency department. Utilizing appropriate and accurate screening and risk stratification tools optimizes clinical decision making and patient outcomes. This review seeks to discuss current evidence on the diagnosis, risk stratification, and evolving management strategies for pulmonary embolism, with a focus on advanced therapeutic intervention and its implications for emergency practice. Methods: We reviewed current literature regarding the epidemiology, diagnosis, risk stratification, and management of PE, with a focus on clinical decision tools and advanced therapeutic interventions. Specific attention was given to diagnostic algorithms, and guidelines regarding risk stratification methods as well as treatment options including catheter-directed thrombolysis (CDT), mechanical thrombectomy, systemic thrombolysis, and ultrasound-assisted thrombolysis (USAT). The literature search was performed using the database PubMed with keywords to include “pulmonary embolism,” “catheter-directed thrombolysis,”, “ultrasound-assisted thrombolysis,” “mechanical thrombectomy,” “systemic thrombolysis,” and “clinical decision support.”. Inclusion criteria included peer-reviewed articles, randomized controlled trials, observational studies, and major guidelines focused on adult patients with acute PE. Exclusion criteria included non-English language publications, case reports, and studies involving pediatric populations. This approach was designed to ensure a thorough and reproducible synthesis of current evidence. Results: Accurate utilization of risk stratification tools has been shown to improve patient-specific treatment and provide a better insight into patient outcomes. Interventional therapies such as CDT and USAT have demonstrated reduced mortality and morbidity in high- and intermediate-risk PE patients when compared to systemic anticoagulation alone. There is also future discussion on how to improve risk stratification to continue to reduce patient mortality and morbidity, as well as reduce the risk of sequelae and side effects. Conclusion: This review article highlights the evolving landscape of PE diagnosis and management driven by advances in risk-stratification tools and interventional therapies. By discussing current evidence, we underscore the importance of accurate risk stratification and the judicious use of different treatment modalities. We also discuss ongoing research focused on refining treatment algorithms, improving the accuracy of clinical decision-making, comparing new and more mature treatment therapies, and preventing long-term complications. The ultimate goal of this review article to provide further discussion on PE to improve patient outcomes.

Sir, 22-year-male, (body mass index 34) with Guillain-Barre Syndrome was on treatment with plasmapheresis. He suddenly became hemodynamically unstable on the 5th day of hospitalization. Arterial blood gas (ABG) showed hypercapnia and later hypoxia. Electrocardiograph showed sinus tachycardia. Echocardiography revealed hypokinesia of the right ventricle and moderate tricuspid regurgitation with pulmonary artery systolic pressure (PASP) of 45 mmHg. The patient continued to be hypoxemic, hypotensive, and suffered a cardiac arrest. In view of deteriorating status, the patient was taken for pulmonary angiography with the intention to diagnose as well treat pulmonary embolism in the same setting. After confirming the diagnosis, mechanical fragmentation was initiated in the embolus followed by intralesional urokinase [Figure 1]. Over the next 24 hrs, hemodynamic parameters gradually improved with the resolution of shock and reduction in pulmonary artery pressure to 27 mmHg. Figure 1 Pulmonary angiography (a) total cut-off of right pulmonary artery (RPA) and clot in left PA (b) mechanical breakdown and intrapulmonary urokinase administration (c) postprocedural pulmonary angiography revealing restoration of pulmonary flow in PA and ... The true incidence of Pulmonary embolism (PE) is unknown because the diagnosis of PE is more often missed than confirmed due of varying clinical presentations. Provisional diagnosis of pulmonary embolism is usually based on the clinical setting and the pretest probability guides the choice of confirmatory tests. This case was at high risk for pulmonary embolism as he was obese with quadriplegia and had been immobilized for almost 1-week. ABG showed respiratory acidosis which in not a common finding in patients of PE, but our patient had neuromuscular paralysis of respiratory and accessory muscles which precluded him from hyperventilation and resulted in respiratory acidosis as the first change in ABG. Thus, the presence of respiratory acidosis on ABG does not exclude the possibility of PE as quoted in one of the recent articles rather blood gas must never be analyzed alone but should be correlated to the clinical scenario.[1] Acute pulmonary embolism is pulmonary embolism resulting in hypotension, shock or need for cardiopulmonary resuscitation (CPR) and is recognized as the third major cause of death among the hospitalized patients. Hence, immediate attention and treatment is crucial. The American college of chest physicians consensus statement have laid down recommendations for management of PE but not more than two-thirds of the patients receive systemic thrombolysis because it is contraindicated (absolute or relative) in a large number of clinical conditions.[2] Since the first description of embolectomy catheter in 1971, the clinical application of catheter-based interventions in the management of acute PE are still very infrequent. There are no randomized controlled trials to compare its efficacy with systemic thrombolysis, with or without anticoagulation. In a recently published meta-analysis, only 594 cases of acute massive PE were treated with catheter-directed therapy (CDT), with a success rate reported to be about 86%.[3] Although our patient was a candidate for systemic thrombolysis, but refractory arterial hypotension and the need for CPR led to the selection of CDT as the modality of choice. Two hour period required for infusion of full dose of tPA and about 20% risk of major hemorrhage following its infusion also led to the selection of CDT as the first line therapy. The catheter-based fragmentation leads to mechanical debulking which can be clinically seen as an immediate improvement in hemodynamics, resolution of shock, and reduction in PASP. However, breakdown of the clot provides a large exposed area for subsequent thrombolysis. The thrombolytic infusion following debulking results in decreasing the incidence of chronic PE and pulmonary hypertension. FDA has approved urokinase (4400 IU/kg intravenous over 10 min, followed by 4400 IU/kg/h for 12 h) and streptokinase (250,000 IU intravenous over 30 min, followed by 100,000 IU/h for 24 h). It is a plasminogen activator with the additional quality of a catalytic agent that renders fibrinogen less clottable by thrombin. Furthermore, in terms of cost and availability it was chosen as the preferred agent. This case highlights that clinicians should have a low threshold for diagnosing PE in acutely bed ridden patients. In a selected group of patients with neurological disorders where systemic thrombolysis is contraindicated, combination of mechanical fragmentation and local thrombolysis may be a promising option for reduction in mortality.

Safety of outpatient treatment in acute pulmonary embolism.

Association of platelet count and mean platelet volume with clinical outcomes in pulmonary embolism: A retrospective cohort study

CLOT IN TRANSIT: THE ROLE OF POINT-OF-CARE ULTRASOUND IN EARLY DIAGNOSIS AND IMPROVED OUTCOMES

How I treat pediatric pulmonary embolism.

We read the paper by Kucher et al, 1 which demonstrated the association between high levels of pro-brain natriuretic peptide (BNP) and increased risk of adverse clinical outcome (death, resuscitation, mechanical ventilation, pressors, thrombolysis, catheter fragmentation, and surgical embolectomy) in patients with acute pulmonary embolism.The authors concluded that patients with acute pulmonary embolism and low pro-BNP levels have an uneventful course and good prognosis.We studied 50 patients with confirmed acute pulmonary embolism prospectively and followed them up for their inhospital course and complications. 2 Echocardiography and BNP measurement were performed in all patients at admission.Thirtyone patients (62%) of our study population had right ventricular (RV) dysfunction (dilatation of the right ventricle with a diastolic diameter Ͼ30 mm, RV/left ventricular end-diastolic diameter ratio Ͼ1, or hypokinesis of the right ventricle).We found that patients without RV dysfunction had significantly lower BNP levels compared with patients with RV dysfunction.There was a significant correlation between RV end-diastolic diameter and BNP.In addition, BNP discriminated between patients with and those without RV dysfunction (area under the receiver operating characteristic, 0.78).A BNP Ͼ90 pg/mL was associated with a risk ratio of 28.4 for the diagnosis of RV dysfunction.However, all patients presenting with syncope necessitating cardiopulmonary resuscitation showed normal BNP levels.Thus, normal BNP levels do not exclude severe pulmonary embolism.This might be due to an insufficient time span for right ventricular BNP production and secretion as a consequence of sudden RV pressure overload resulting in syncope with cardiac arrest in these patients.All of the patients with syncope and normal BNP levels showed elevated troponin T levels, stressing the value of troponin T measurements in identifying patients with severe pulmonary embolism.Kucher et al 1 mention that a possible limitation of their study lies in the absence of serial pro-BNP testing and thus in an underestimation of pro-BNP elevation given the possible transient nature of its release.Indeed, in our study, we found highly dynamic BNP release kinetics with rapidly falling BNP levels after initiation of therapy aimed at improving RV dysfunction, especially after thrombolysis.On the other hand, in patients admitted with subacute pulmonary embolism Ͼ2 days after onset of symptoms, we still found BNP levels significantly elevated.Overall, we found BNP levels not to be predictive for mortality or in-hospital complications.Patients with RV dysfunction as determined by echocardiography had significantly more in-hospital complications, confirming that echocardiography remains the bedside gold standard for the detection of RV dysfunction.Further studies in larger patient populations possibly comparing pro-BNP and BNP kinetics and their respective predictive values appear warranted.

What's in this Issue