Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension: A Scientific Statement From the American Heart Association

Conclusions:

The following are 10 points to remember about this scientific statement from the American Heart Association:

1. This expert consensus reviews the optimal use of advanced therapies in the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT), and chronic thromboembolic pulmonary hypertension (CTEPH).

2. Massive PE is an acute PE with sustained hypotension (systolic blood pressure <90 mm Hg) for at least 15 minutes or requiring inotropic support due to the PE; submassive PE is an acute PE without systemic hypotension (systolic blood pressure >90 mm Hg), but with either right ventricular (RV) dysfunction or myocardial necrosis (B-type natriuretic peptide [BNP] >90 pg/ml or cardiac troponin I >0.4 ng/ml); and low-risk PE is an acute PE and the absence of the clinical markers of adverse prognosis that define massive or submassive PE.

3. Patients with objectively confirmed PE and no contraindications should receive prompt anticoagulant therapy. Those with intermediate or high clinical probability of PE should be given anticoagulant therapy during the diagnostic workup.

4. Patients with low-risk PE have an unfavorable risk-benefit ratio with fibrinolysis. Fibrinolysis is reasonable for patients with a massive acute PE. Management of submassive PE includes fibrinolysis in the presence of one of two criteria: 1) respiratory insufficiency defined as a pulse oximetry reading <95% when the patient is breathing room air and clinical judgment that the patient appears to be in respiratory distress; or 2) RV injury by echo-Doppler including RV hypokinesis, regional akinesis, septal shift, or RV systolic pressure >40 mm Hg, or an elevated cardiac troponin I or BNP.

5. Fibrinolytic therapy is recommended with alteplase 100 mg via a peripheral intravenous catheter over 2 hours during which anticoagulation is withheld. It is preferable to confirm the diagnosis of PE with imaging before fibrinolysis is initiated. When direct imaging is unavailable or unsafe because of the patient’s unstable condition, an alternative approach favors aggressive early management, including fibrinolysis, of the patient with sustained hypotension, and when there is a high clinical pretest probability of PE and RV dysfunction on bedside echocardiography.

6. In massive PE, depending on local expertise, percutaneous techniques to recanalize pulmonary trunk or major pulmonary arteries by catheter embolectomy and fragmentation or surgical embolectomy is reasonable in patients with contraindications to fibrinolysis or remaining unstable after fibrinolysis.

7. Adults with confirmed acute PE or proximal DVT with contraindications to or bleeding with anticoagulants and those with recurrent PE or DVT on anticoagulants should receive an inferior vena cava (IVC) filter. Retrievable IVC filter should be used when indication is time-limited and considered for removal when no longer necessary.

8. IFDVT patients should receive initial anticoagulant therapy for the prevention of PE and recurrent DVT. Patients should receive oral warfarin overlapped with initial anticoagulants for a minimum of 5 days and until the international normalized ratio is ≥2. First episode IFDVT with a major reversible risk factor should be treated for 3 months. Recurrent and unprovoked IFDVT should have at least 6 months of anticoagulation with consideration for longer-term. Cancer patients should receive low molecular weight heparin for at least 3-6 months or as long as cancer and treatment are ongoing. There is added benefit from the daily use of sized-to-fit 30-40 mm Hg knee-high graduated elastic compression stockings (ECS) for 2 years after the diagnosis of first-episode proximal DVT. Patients with prior IFDVT and symptomatic post-thrombotic syndrome (PTS) should have long-term ECS. Catheter-directed thrombolysis (CDT), surgical thrombectomy, and percutaneous mechanical thrombectomy (PCDT) need to be considered when IFDVT is associated with limb-threatening circulatory compromise.

9. Stent placement in the iliac vein to treat obstructive lesions after CDT, PCDT, or surgical venous thrombectomy is reasonable, as is the placement of iliac vein stents to reduce PTS symptoms and heal venous ulcers in patients with advanced PTS.

10. Patients presenting with unexplained dyspnea, exercise intolerance, or clinical evidence of right-sided heart failure, with or without prior history of symptomatic VTE, should be evaluated for CTEPH. It is reasonable to evaluate patients with an echocardiogram 6 weeks after an acute PE to screen for persistent pulmonary hypertension that may predict the development of CTEPH. Patients with proven CTEPH should be promptly evaluated for pulmonary endarterectomy, even if symptoms are mild. Pulmonary arterial hypertension–specific medical therapy may be considered for patients with CTEPH who are not surgical candidates or who have residual pulmonary hypertension not amenable to re-operation.

Perspective:

This is an outstanding review that should be read by all cardiovascular specialists and others involved in the care of patients with acute and chronic venous thromboemboli. I suspect that few physicians and institution practice patterns are in lock step with the suggestions.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and Imaging, Interventions and Vascular Medicine, Echocardiography/Ultrasound

Keywords: Vena Cava, Inferior, Pulmonary Embolism, Respiratory Insufficiency, Peripheral Vascular Diseases, Stents, Thromboembolism, Biological Markers, Embolectomy, Thrombectomy, Heart Failure, Venous Thrombosis, United States, Echocardiography


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