Everything You Need to Know About Managing High-Risk PE…Mostly
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One third of eligible patients with high-risk pulmonary embolism (PE) receive systemic thrombolysis (ST) despite demonstrated mortality benefit. This review provides a comprehensive overview of current evidence on assessment and management of high-risk PE, with emphasis on reperfusion therapies.
Source
Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med. Published online February 3, 2024. doi:10.1016/j.ajem.2024.01.039
Why Are More PE Patients Dying?
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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.
Mortality of High-Risk PE Is, Well…High
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A prospective study by the PERT Consortium found an in-hospital mortality rate of 20% in patients with high-risk PE. 41.9% of patients with high-risk PE were treated with advanced therapies (systemic thrombolytics, catheter-directed thrombolysis or embolectomy, surgical embolectomy, ECMO).
Source
Contemporary Management and Outcomes of Patients With High-Risk Pulmonary Embolism. J Am Coll Cardiol. 2024;83(1):35-43. doi:10.1016/j.jacc.2023.10.026
FLAME Massive PE Study – FlowTriever for Intravascular Thrombectomy
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In this non-randomized prospective trial, patients with massive pulmonary embolism who were treated with the intravascular FlowTriever thrombectomy device had improved outcomes compared to those treated with other therapies.
Source
Outcomes in High-Risk Pulmonary Embolism Patients Undergoing FlowTriever Mechanical Thrombectomy or Other Contemporary Therapies: Results From the FLAME Study. Circ Cardiovasc Interv. 2023;16(10):e013406.
NSAIDs + OCPs = More VTEs?
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This Danish nationwide cohort study found that in reproductive-age women, NSAID use alone increased the risk of venous thromboembolism (VTE). The magnitude of risk was compounded by concomitant use of hormonal contraception.
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Venous thromboembolism with use of hormonal contraception and non-steroidal anti-inflammatory drugs: nationwide cohort study. BMJ 2023; 382 :e074450 doi:10.1136/bmj-2022-074450.
Anchoring – Does Information from Triage Bias Our Workup?
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Veterans Affairs (VA) patients with known congestive heart failure (CHF) presenting for shortness of breath as a chief complaint were less likely to receive testing for venous thromboembolism (VTE) when triage reported CHF.
Source
Evidence for Anchoring Bias During Physician Decision-Making. JAMA Intern Med. 2023 Aug 1;183(8):818-823. doi: 10.1001/jamainternmed.2023.2366.
DOACs and Diapers? Direct Oral Anticoagulants in Pediatrics
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Treatment with direct oral anticoagulants (DOACs) in pediatric patients appears to reduce venous thromboembolism (VTE) recurrence compared to standard of care, with no difference in major bleeding or serious adverse events. Prophylaxis with DOACs was comparable to standard of care and was associated with a nonsignificant reduction in VTE.
Source
Efficacy and safety of direct oral anticoagulants in the pediatric population: a systematic review and a meta-analysis. J Thromb Haemost. 2023 Jul 20:S1538-7836(23)00573-1. doi: 10.1016/j.jtha.2023.07.011. Epub ahead of print.
Subsegmental PE – Hold the Anticoagulation?
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Structured surveillance without anticoagulation of patients with isolated subsegmental pulmonary embolism (ssPE) rarely occurs in community practice. After applying CHEST guidelines, ~5% of patients with isolated subsegmental PE are eligible for surveillance.
Source
Prevalence of and Eligibility for Surveillance Without Anticoagulation Among Adults With Lower-Risk Acute Subsegmental Pulmonary Embolism. JAMA Netw Open. 2023;6(8):e2326898. Published 2023 Aug 1. doi:10.1001/jamanetworkopen.2023.26898
Should We Now Use DOACs for PE?
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Direct oral anticoagulants (DOACs) are safe and effective for the treatment of pulmonary embolism (PE).
Point | Counterpoint – Lytics + Heparin or Heparin Alone for Intermediate Risk PE?
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There is practice variation in the treatment of patients with intermediate-risk pulmonary embolism (PE). The treatment threshold for which fibrinolytics should be added to standard anticoagulation in hemodynamically stable patients at risk for decompensation has been a focus of PE research for the last decade.
Source
Treatment of Intermediate-Risk Pulmonary Embolism. N Engl J Med. 2023 Jul 13;389(2):184-187. doi: 10.1056/NEJMclde2301330.