Anticoagulation should be the preferred method for treated patient with acute pulmonary embolism (PE), with more invasive treatment reserved for those at higher risk, according to a perspective from ACC’s Interventional Council published Feb. 22 in the Journal of the American College of Cardiology.

Most patients with massive and submassive PE continue to be treated with only anticoagulation, despite high fatality rates. Because of the difficulty of treating PE patients, hospitals have formed multidisciplinary pulmonary embolism response teams (PERTs) to discuss treatment options and provide therapy for these patients. The Council recommends that, at a minimum, a PERT should include representatives from medicine, interventional cardiology/radiology and surgery.

According to the Council, prior to any interventions, anticoagulation, usually with intravenous heparin, should be initiated when PE is suspected. The PERT should meet to examine patient data and discuss indication and contraindications to fibrinolytic therapy, catheter-based intervention and surgical embolectomy. These options should then be discussed with the patient and family members.

The Council also examined the data surrounding systemic fibrinolysis, catheter-based therapies, extracorporeal mechanical oxygenation and right ventricular assist devices, surgical embolectomy, and vena cava filter. They explain that while the data surrounding these therapies are limited, there are certain patient groups that may see better outcomes as a result of these treatments. However, the Council did not find enough support to recommend these treatment options beyond the highest-risk patients.

“At this time, there is not enough evidence to strongly support routine utilization of any of the previously discussed techniques in the management of submassive or massive PE, beyond anticoagulation,” the Council concludes. “Most PE patients should continue to be treated conservatively, with aggressive treatment options reserved for those at high- or intermediate-high-risk without contraindications.” They add that “Until appropriate studies fill knowledge gaps, we recommend utilization of multidisciplinary PERTs and collection and sharing of data in registries or formal studies.” 

Keywords: Embolectomy, Fibrinolysis, Heart-Assist Devices, Heparin, Pulmonary Embolism, Thrombolytic Therapy, Vena Cava Filters, Cardiology Magazine

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