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):
- PE is a major contributor to global disease burden, including a high short-term mortality risk.
- 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.
- 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.
- 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).
- Primary systemic fibrinolysis has an unfavorable risk-benefit ratio in intermediate-risk PE.
- Low-risk patients have hemodynamic stability and negative biomarkers. Management includes systemic anticoagulation.
- 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).
- Recent trial data do not support the routine use of inferior vena cava filters in patients who can receive anticoagulation therapy.
- 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.
- Campaigns to increase the awareness of PE and to implement guideline-recommended treatment are critical for optimizing PE management.
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