Written by Carmen Wolfe
Spoon Feed
Mortality in patients with high-risk pulmonary embolism (PE) in the United States increased over the last decade. Surprised? Here’s why this might be true, and what we should do about it.
Is PE deadlier than ever?
Yesterday, we covered how dangerous high-risk PE is, and mortality in this group appears to be increasing. This spectacular article decodes recent epidemiologic data and research efforts regarding PE. As defined by the ESC guidelines, patients with high-risk PE experience hemodynamic instability – defined by cardiac arrest, obstructive shock, or persistent SBP < 90 mmHg.1 Mortality in this high-risk subgroup appears to have increased by nearly 100% in the United States from 2009 to 2019.2 This might be due to an aging population with greater comorbidities, increased recognition and classification of deaths, increased incidence due to the SARS-CoV2-2 pandemic, or under-treatment of PE.
How can we turn the tide on this concerning trend? The authors make a few suggestions:
- Presumptively anticoagulate patients prior to imaging results.
- Utilize systemic thrombolysis in high-risk PE if no contraindications (optimal dosing still TBD).
- Consider catheter-directed therapies, though more evidence is needed.
- Create PE Response Teams (PERTs).
What about patients who don’t quite meet high-risk criteria? The ESC defines this group as intermediate-high-risk when right ventricular dysfunction and elevated troponin are both present. What strategies do we have here?
- Continue research to identify prognostic markers that may help guide management.
- Follow consensus guidelines and utilize LMWH or fondaparinux rather than unfractionated heparin in hemodynamically stable patients.
- Increase awareness and await results of ongoing trials regarding reduced-dose systemic thrombolysis, catheter-directed thrombolysis, or mechanical thrombectomy in this intermediate-high-risk cohort.
How will this change my practice?
Knowing these concerning trends, I will do what I can to help reverse them. I’ll carefully examine my own practice to ensure I’m following consensus guidelines, suggest development of a PE Response Team at my hospital, and eagerly awaiting upcoming trial results.
Author Commentary: “Although the care of acute PE has advanced tremendously over the past decade and the overall mortality of non-high-risk PE appears stable, research effort dedicated to improving the management of the higher-risk subgroups is needed.” -Bo Stubblefield
Also, thanks to Bo for reviewing this post.
Source
Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities. Acad Emerg Med. Published online December 21, 2023.
Works Cited
- Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J. 2019;54(3).
- Zuin M, Bikdeli B, Davies J, et al. Contemporary trends in mortality related to high-risk pulmonary embolism in US from 1999 to 2019. Thrombosis research. 2023;228:72-80.
