VTE Week | Bo’s Epic PE Review

September 18, 2020

Written by Bo Stubblefield

Spoon Feed
This manuscript provides a detailed review of the diagnosis, management, and treatment of pulmonary embolism (PE).

Why does this matter?
The risk assessment, diagnosis, and management of PE has evolved over the last decade. It is valuable to maintain an up-to-date understanding of this potentially critical cardiovascular illness. Duffett, et al provide a high-level review of past, present, and future PE management in this work.

One stop shop for a review of the PE Lit.
This was a detailed, comprehensive review. The authors searched several databases from 2010 to 2019 for systematic reviews, meta-analyses, and RCTs that evaluated management of PE. They also included clinical practice guidelines. Here is what you need to know:

Epidemiology

• Venous Thromboembolism (VTE) is the third most common cardiovascular disorder and affects 5% of population during their lifetime. 

Diagnosis: Decision tools & D-dimer

• Use clinical pre-test probability before testing.

• Use your clinical decision tools: PERC, Wells, Geneva.

• Adjust your D-dimer: YEARS, Age-adjusted, Gestalt.

Diagnosis in Pregnancy

• Apply YEARS with your D-dimer, and utilize lower extremity ultrasonography for suspected DVT.

• Ventilation Perfusion (VQ) scans in pregnant women are supported by ASH.

• Both VQ scans and CTPA are safe and accurate diagnostic imaging modalities in pregnancy. Fetal exposure to radiation well under acceptable limits for both tests.

Diagnosis of recurrent pulmonary embolism

• Patients with a history of VTE have a lifetime of increased risk for recurrent events.

• The combination of a low clinical probability and negative D-dimer can be used to exclude PE in patients with a prior history of VTE and is supported by ISTH.

• Interpretation of diagnostic imaging for a suspected recurrent event requires comparison with prior imaging to prevent over-diagnosis.

Risk Assessment: Outpatient v. inpatient

• Use PESI, sPESI, or Hestia Criteria to risk stratify once you make the diagnosis of PE.

• Low-risk patients with PE or DVT may be managed on an outpatient basis with a direct oral anticoagulant (DOAC). This is supported ESC and has a grade C reccommendation from ACEP.

Subsegmental PE

• Increased sensitivity of imaging modalities has led to an increase in single or multiple pulmonary emboli isolated to smaller, subsegmental pulmonary arteries, but the case fatality rate has remained stable or decreased.

• Further studies are ongoing to determine if subsegmental PE in the absence of DVT may be treated without anticoagulation.

Choice of anticoagulation for acute PE 

• Low molecular weight heparin (LMWH) is recommended for patients unless acute intervention is suspected or renal failure is present.

• Each DOAC was deemed non-inferior to warfarin/LMWH in phase III RCTs.

• DOACs have fewer major bleeding events when compared to warfarin.

Thrombolysis for acute PE

• Systemic thrombolytic therapy (tPA) is reserved for massive PE (hemodynamic instability).

• Observation in a monitored setting with thrombolytic therapy is reserved for clinical deterioration in high-risk patients (i.e. RV dysfunction + elevated cardiac biomarkers).

Embolectomy & ECMO

• These procedures may be performed in patients with hemodynamic instability and a contraindication to thrombolysis.

• Both are promising alternatives by recent studies, though more studies are needed.

Long-term effects, physiological impact, & quality of life

• Up to 50% of patients report long-term sequelae following their PE.

• Post-pulmonary artery syndrome is an emerging diagnosis that consists of suboptimal cardiac function, pulmonary artery flow dynamics, or pulmonary gas exchange combined with dyspnea, decreased exercise tolerance, or diminished functional status or quality of life without an alternative explanation.

• Chronic thromboembolic pulmonary hypertension (CTEPH) lies at the extreme end of poor outcomes and occurs in ~3% of patients at 6 months.

• A diagnosis of PE has significant psychological impact and affects quality of life, particularly in cancer patients. This is a much needed and emerging field within VTE research.

Another Spoonful
Interested in further bulking up your PE knowledge? Here are five great reads and a testimonial to ‘know thy
history!’

1. Emergency Evaluation for Pulmonary Embolism, Part 1: Clinical Factors that Increase Risk

2. Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach

3. Diagnosis and Exclusion of Pulmonary Embolism

4. Venothromboembolic signs and medical eponyms: Part I

5. Venothromboembolic signs and medical eponyms: Part II 

Source
Pulmonary embolism: update on management and controversies. BMJ. 2020;370:m2177. Published 2020 Aug 5. doi:10.1136/bmj.m2177

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Reviewed by Clay Smith