Management of PE

Introduction and Scope of the Problem

The incidence of venous thromboembolism (VTE), including pulmonary embolism (PE) and deep venous thromboembolism (DVT), in the United States is unclear because there is no national surveillance system. However, PE is considered to be the third most common cause of cardiovascular death, with 60,000-100,000 deaths per year.1-3 This is likely an underestimation because PE can result in unexplained sudden cardiac death. Treatment varies depending on the severity of the disease and the center's expertise and resources. A consensus document was recently issued by the Pulmonary Embolism Response Team (PERT) Consortium, which endorses a PERT approach to high- and intermediate-risk cases by a multidisciplinary team. This team includes, but is not limited to, cardiac surgery, cardiology, hematology, critical care, vascular medicine, vascular surgery, and radiology specialists who discuss complex cases and expedite treatment decisions.4

Diagnosis and Risk Stratification

PE presenting symptoms are variable, thus making the diagnosis challenging (Table 1). Once PE is suspected, a determination of pretest probability using either the Wells or Geneva scores may be used.5,6 In cases of low and intermediate pretest probability, testing D-dimer is helpful because a negative result may be used to rule out PE. The PE rule-out criteria can also be used in cases of low pretest probability. Using this rule, PE can be ruled out without further imaging if there is absence of any of the following:7

  • Age ≥50
  • Heart rate ≥100
  • Saturation on room air <95%
  • Leg swelling
  • Hemoptysis
  • Recent trauma or surgery
  • History of PE or DVT
  • Hormonal therapy

For patients with intermediate or high pretest probability or a positive D-dimer, a contrast-enhanced chest computed tomography (CT) angiography is indicated.

Table 1: Signs and Symptoms Associated With PE

Symptoms
Dyspnea
Chest pain
Palpitations
Dizziness
Syncope
Flank tenderness (pulmonary infarction)
Signs on Physical Exam
Tachycardia
Tachypnea
Right ventricular (RV) strain
Jugular vein distension
Loud S2
Pulsatile liver
Parasternal heave
Electrocardiographic Findings
Sinus tachycardia
Anterior precordial T Wave inversion
S1Q3T3
Precordial ST-segment elevation
Echocardiographic Findings
Right heart dilation
Septal shift
McConnell's sign: RV free wall akinesis sparing the apex
Imaging Findings
Hampton hump: wedge opacity in the setting of pulmonary infarct
Westermark sign: Prominent pulmonary artery with decreased peripheral vasculature
DVT per ultrasound

Once a PE is diagnosed, the patient should be risk stratified (Table 2). Short-term mortality in PE is driven by hemodynamic derangements and RV failure. Patients with low-risk PE are generally treated with anticoagulation and may not merit admission to the hospital. Further, patients with a single sub-segmental PE but no DVT, active cancer, or symptoms may not require anticoagulation.8 Patients with massive (high-risk) PE require immediate intervention including thrombolytics and thrombectomy, with or without mechanical hemodynamic support. Normotensive patients are further risk stratified using clinical scores such as the Pulmonary Embolism Severity Index (PESI)9 and its simplified version, sPESI,10 biomarkers, and imaging modalities that detect RV strain. The presence of RV strain by both biomarkers and imaging indicates a high-risk, submassive PE and portends worse prognosis, which may merit more aggressive treatment.11

Table 2: Risk Stratification and Treatment of PE

  Low Risk Intermediate Risk (Submassive) High Risk (Massive)
Presentation
  • Normotensive
  • Low risk per PESI and sPESI
  • Normal biomarkers
  • PESI class III-IV
  • sPESI ≥1
  • Echo or CT evidence of RV strain
  • Positive troponin
  • Elevated B-type natriuretic peptide or N-terminal B-type natriuretic peptide
  • Hypotension (systolic blood pressure <90 mmHg for ≥15 min, drop in systolic blood pressure of ≥40 mmHg or vasopressor)
  • Thrombus in transit
  • Syncope
  • Cardiac arrest
Treatment
  • Anticoagulation: Direct oral anticoagulants are preferred
  • Candidates for early discharge
  • Anticoagulation: Consider unfractionated heparin over others if any of the therapies below are possible
  • Systemic thrombolytic (100 mg over 2 h)
  • High risk of bleeding: Half-dose thrombolytic (50 mg over 2 h)
  • Catheter-directed therapy
  • Surgical embolectomy
  • High-risk PE and cardiogenic shock: Mechanical support to allow stability for thrombolysis, catheter-directed therapy, or surgical embolectomy

Treatment

Anticoagulation should be initiated as soon as the diagnosis of PE is suspected.8 Unfractionated heparin may be preferred in patients who are candidates for further advanced therapies such as thrombolysis, catheter-directed thrombolytics or embolectomy, or surgical embolectomy because it provides more flexibility for procedures.4 Direct oral anticoagulants are first-line therapy for low-risk patients and intermediate- and high-risk patients once they have achieved hemodynamic stability.8,12 Systemic thrombolytic therapy should be considered in massive PE due to observed reduction in mortality and recurrence.13 Systemic thrombolytic therapy may be considered in high-risk submassive PE in the absence of contraindications because it has been shown to improve hemodynamics, reverse RV dilatation, and prevent hemodynamic decompensation, though no significant short-term mortality reduction has been observed.8,14 Unfortunately, systemic thrombolytic therapy is associated with significant bleeding, including a 6% risk of major bleeding and up to 3% of intracranial hemorrhage (ICH).14,15 In patients with relative contraindications to systemic thrombolytic therapy, half-dose thrombolytic can be used because it provides similar improvements in RV strain and pulmonary artery pressures.16

Catheter-Directed Therapy

Given the significant risks of systemic thrombolytic therapy including ICH, catheter-directed approaches have been developed to reduce the dose of thrombolytics used or avoid thrombolytics altogether (Table 3). This technology has been tested in randomized controlled trials using the endpoint of improvement in RV/left ventricular (LV) ratio because this predicts mortality and adverse outcomes.17 Safety endpoints include major bleeding, mortality, and recurrent PE. Two primary approaches are currently used. The first, catheter-directed thrombolytics, involves local delivery of lytic therapy to the pulmonary arteries. This may be performed using a standard pigtail catheter or pulmonary artery catheter to deliver the lytics locally. Alternatively, the lytics may be delivered using the EKOS EkoSonic (BTG PLC; London, UK) catheter for ultrasound-assisted catheter-directed thrombolysis. This catheter uses locally delivered ultrasound to separate fibrin strands in the thrombus, potentially enhancing penetration of the thrombolytic. The second catheter-directed approach includes mechanical thrombectomy, which may be used in isolation or in combination with lytic therapy based on the clinical scenario. The catheter systems currently approved for this indication include the Penumbra Indigo (Penumbra, Inc.; Alameda, CA) and FlowTriever (Inari Medical, Inc.; Irvine, CA) catheters. Other systems are currently under development or investigation for this indication. There are no published head-to-head trials comparing the various systems or comparing catheter-directed therapy to systemic thrombolysis. Therefore, the choice of modality should be based on local expertise and availability. Overall, the risk associated with catheter-directed therapies is low, with a 0.35% risk of ICH and 4.6% risk of major complications.18 Therefore, guidelines recommend use of catheter-directed lytics in intermediate-high-risk PE with relative contraindications to thrombolytic and use of catheter-directed thrombectomy in patients with absolute contraindications to thrombolytics or failed thrombolytic therapy.4

Table 3: Catheter-Directed Therapy

Device Sheath Technique TrialREF and Indications
Ultrasound-Assisted Thrombolysis
EkoSonic 5.2 Fr High-frequency, low-power ultrasound waves aim to disrupt the clot allowing lytic to penetrate clot with a lower dose requirement ULTIMA (Ultrasound Accelerated Thrombolysis of Pulmonary Embolism)19
  • 20 mg tPA
  • 0.3 difference in RV/LV ratio
  • 0% major bleeding
SEATTLE II (Submassive and Massive Pulmonary Embolism Treatment With Ultrasound Accelerated Thrombolysis Therapy)20
  • 24 mg of tPA
  • 0.42 difference in RV/LV ratio
  • 10% major bleeding, no ICH
OPTALYSE-PE (Optimum Duration of Acoustic Pulse Thrombolysis Procedure in Acute Pulmonary Embolism)21
  • 4-12 mg of tPA for 2-6 hrs
  • 0.3-0.4 difference in RV/LV ratio
  • 1 episode of ICH in the arm of 12 mg over 6 h
  • Overall risk of bleeding of 4%
Suction Thrombectomy
Indigo 4, 6, 8 Fr High-velocity
vacuum suction catheter
EXTRACT PE (Evaluating the Safety and Efficacy of the Indigo® Aspiration System in Acute Pulmonary Embolism)
  • 0.43 reduction (in the RV/LV ratio after 48 hours
  • Small caliber
FlowTriever 20 Fr Large aspiration guide catheter, device has 3 self-expanding nitinol disks unsheathed to disrupt and aspirate clot FLARE (FlowTriever Pulmonary Embolectomy Clinical Study)22
  • No tPA required
  • Major bleeding rate 0.9%

Surgical Embolectomy

Surgical embolectomy is recommended in patients with high-risk or intermediate-high-risk PE with absolute contraindications to thrombolytic therapy, failed thrombolytic therapy, or cardiogenic shock that may cause death prior to thrombolytic therapy. Surgical embolectomy is often considered as first-line therapy for patients with thrombus in the right heart or across a patent foramen ovale (clot-in-transit). The risk of the procedure depends on the patient's baseline hemodynamic status and comorbidities, but it has been reported to be ≤11%.23,24

Mechanical Circulatory Support

In patients with high-risk PE and cardiogenic shock, cardiac arrest, or impending hemodynamic collapse, further mechanical support should be considered. Venoarterial extracorporeal membrane oxygenation (VA ECMO) is effective when used in combination with any of the above treatments with good survival rates and low complication risks.25,26 VA ECMO provides complete hemodynamic support with up to 5-6 L of output in conjunction with an oxygenator, which provides oxygenation and ventilation support. Importantly, as it bypasses the pulmonary circulation, it reduces the RV pre-load and reduces RV distention while having no effect on the pulmonary artery pressure. RV support with heart pumps has also been described in case reports in the setting of PE. These devices deliver blood directly into the pulmonary artery. Studies have not compared these modalities to VA ECMO in the setting of PE.

Supportive Care and Follow-Up

In patients with PE who cannot tolerate anticoagulation, current guidelines recommend the use of inferior vena cava filters.8 The addition of inferior vena cava filters to anticoagulation has not been demonstrated to be beneficial in prospective trials but may be considered in patients with large, mobile, or proximal DVT.4,27,28 Retrievable filters should be removed as soon as possible. Finally, patients should be followed in the outpatient setting to assess for recurrent PE, guide further anticoagulation, complete a comprehensive coagulopathy evaluation, and assess for possible persistent RV dysfunction and chronic thromboembolic disease.4

Conclusions

PE is a common clinical problem with varied manifestations ranging from benign to fatal. Given the complexities of diagnostic, stabilization, and treatment modalities, a rapidly assembled and collaborative multi-disciplinary approach is helpful. Further development of treatment options and randomized clinical trials are needed to delineate optimal approaches for these patients. The consensus document published by the PERT consortium provides a foundation for the decision-making required for these patients.

References

  1. Benjamin EJ, Muntner P, Alonso A, et al. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019;139:e56-e528.
  2. Morrone D, Morrone V. Acute Pulmonary Embolism: Focus on the Clinical Picture. Korean Circ J 2018;48:365-81.
  3. Blood Clots: A Serious but Preventable Medical Condition (Centers for Disease Control and Prevention website). May 4, 2016. Available from: http://www.cdc.gov/ncbddd/dvt/documents/blood-clots-fact-sheet.pdf. Accessed January 1, 2020.
  4. Rivera-Lebron B, McDaniel M, Ahrar K, et al. Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium. Clin Appl Thromb Hemost 2019;25:1076029619853037.
  5. Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 2000;83:416-20.
  6. Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 2006;144:165-71.
  7. Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004;2:1247-55.
  8. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016;149:315-52.
  9. Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005;172:1041-6.
  10. Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010;170:1383-9.
  11. Stein PD, Matta F, Janjua M, Yaekoub AY, Jaweesh F, Alrifai A. Outcome in stable patients with acute pulmonary embolism who had right ventricular enlargement and/or elevated levels of troponin I. Am J Cardiol 2010;106:558-63.
  12. Groetzinger LM, Miller TJ, Rivosecchi RM, Smith RE, Gladwin MT, Rivera-Lebron BN. Apixaban or Rivaroxaban Versus Warfarin for Treatment of Submassive Pulmonary Embolism After Catheter-Directed Thrombolysis. Clin Appl Thromb Hemost 2018;24:908-13.
  13. Wan S, Quinlan DJ, Agnelli G, Eikelboom JW. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials. Circulation 2004;110:744-9.
  14. Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014;370:1402-11.
  15. Konstantinides S, Tiede N, Geibel A, Olschewski M, Just H, Kasper W. Comparison of alteplase versus heparin for resolution of major pulmonary embolism. Am J Cardiol 1998;82:966-70.
  16. Wang C, Zhai Z, Yang Y, et al. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism: a randomized, multicenter, controlled trial. Chest 2010;137:254-62.
  17. Meinel FG, Nance JW Jr, Schoepf UJ, et al. Predictive Value of Computed Tomography in Acute Pulmonary Embolism: Systematic Review and Meta-analysis. Am J Med 2015;128:747-59.e2.
  18. Bloomer TL, El-Hayek GE, McDaniel MC, et al. Safety of catheter-directed thrombolysis for massive and submassive pulmonary embolism: Results of a multicenter registry and meta-analysis. Catheter Cardiovasc Interv 2017;89:754-60.
  19. Kucher N, Boekstegers P, Müller OJ, et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation 2014;129:479-86.
  20. Piazza G, Hohlfelder B, Jaff MR, et al. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study. JACC Cardiovasc Interv 2015;8:1382-92.
  21. Tapson VF, Sterling K, Jones N, et al. A Randomized Trial of the Optimum Duration of Acoustic Pulse Thrombolysis Procedure in Acute Intermediate-Risk Pulmonary Embolism: The OPTALYSE PE Trial. JACC Cardiovasc Interv 2018;11:1401-10.
  22. Tu T, Toma C, Tapson VF, et al. A Prospective, Single-Arm, Multicenter Trial of Catheter-Directed Mechanical Thrombectomy for Intermediate-Risk Acute Pulmonary Embolism: The FLARE Study. JACC Cardiovasc Interv 2019;12:859-69.
  23. Keeling WB, Sundt T, Leacche M, et al. Outcomes After Surgical Pulmonary Embolectomy for Acute Pulmonary Embolus: A Multi-Institutional Study. Ann Thorac Surg 2016;102:1498-502.
  24. Leacche M, Unic D, Goldhaber SZ, et al. Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg 2005;129:1018-23.
  25. George B, Parazino M, Omar HR, et al. A retrospective comparison of survivors and non-survivors of massive pulmonary embolism receiving veno-arterial extracorporeal membrane oxygenation support. Resuscitation 2018;122:1-5.
  26. Yusuff HO, Zochios V, Vuylsteke A. Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a systematic review. Perfusion 2015;30:611-6.
  27. Mismetti P, Laporte S, Pellerin O, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. JAMA 2015;313:1627-35.
  28. Stein PD, Matta F, Lawrence FR, Hughes MJ. Usefulness of Inferior Vena Cava Filters in Unstable Patients With Acute Pulmonary Embolism and Patients Who Underwent Pulmonary Embolectomy. Am J Cardiol 2018;121:495-500.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging

Keywords: Venous Thromboembolism, Pulmonary Embolism, Anticoagulants, Angiography, Coronary Angiography, Heparin, Hemoptysis, Heart Rate, Consensus, Dilatation, Pulmonary Artery, Specialization, Embolectomy, Thrombolytic Therapy, Fibrinolytic Agents, Thrombectomy, Intracranial Hemorrhages, Hematology, Cardiac Surgical Procedures, Death, Sudden, Cardiac, Critical Care, Neoplasms, Prognosis, Risk Assessment, Patient Care Team


< Back to Listings