Update of Pulmonary Embolism Management

Konstantinides SV, Barco S, Lankeit M, Meyer G.
Management of Pulmonary Embolism: An Update. J Am Coll Cardiol 2016;67:976-990.

The following are key points to remember from this review on the management of pulmonary embolism (PE):

  1. PE is a major contributor to global disease burden, including a high short-term mortality risk.
  2. Clinical prediction rules (e.g., Wells or revised Geneva) should be used to assess the pretest probability of a PE diagnosis before laboratory or imaging procedures.
    • Age-adjusted cutoff levels increase the specificity of D-dimer testing and may decrease the overuse of imaging procedures and PE diagnosis for low pretest probability patients.
    • Imaging studies (usually computed tomography angiography) are recommended as first-line tests for intermediate-high pretest probability patients.
  3. High-risk patients (massive PE) present with shock or persistent arterial hypotension as a result of overt right ventricular failure.
    • Management usually includes systemic fibrinolysis (both full-dose and half-dose regimens appear effective).
    • Catheter-directed techniques are an option for patients with hemodynamic decompensation and high bleeding risk for whom systemic fibrinolysis may not have a favorable risk-benefit ratio.
  4. Intermediate-risk patients (submassive PE) have hemodynamic stability upon presentation, but evidence of right ventricular dysfunction and positive biomarkers (troponin or B-type natriuretic peptide).
  5. Primary systemic fibrinolysis has an unfavorable risk-benefit ratio in intermediate-risk PE.
  6. Low-risk patients have hemodynamic stability and negative biomarkers. Management includes systemic anticoagulation.
  7. Anticoagulation treatment for acute PE should cover at least 3 months. Direct oral anticoagulants (e.g., dabigatran, rivaroxaban, apixaban, and edoxaban) are effective and safe alternatives to standard anticoagulation regimens (heparin + warfarin).
  8. Recent trial data do not support the routine use of inferior vena cava filters in patients who can receive anticoagulation therapy.
  9. Current controversies in acute PE management include the need for anticoagulation in subsegmental PE patients, diagnosis and management of acute PE in pregnancy, use of direct oral anticoagulants in cancer-associated PE, duration of anticoagulation for first-time PE patients, and the role of outpatient management of “low-risk” PE.
  10. Campaigns to increase the awareness of PE and to implement guideline-recommended treatment are critical for optimizing PE management.

Clinical Topics: Anticoagulation Management, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism, Heart Failure and Cardiac Biomarkers, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging

Keywords: Angiography, Anticoagulants, Biological Markers, Diagnostic Imaging, Fibrinolysis, Hemodynamics, Heparin, Hypotension, Natriuretic Peptide, Brain, Pulmonary Embolism, Risk Management, Secondary Prevention, Tomography, Troponin, Vena Cava Filters, Venous Thromboembolism, Ventricular Dysfunction, Right, Warfarin

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