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Division of PULMONARY &

CRITICAL CARE MEDICINE

Pulmonary Embolism:

Issues in Stratification, Prognosis

and Management

Sean M. Caples, D.O., M.Sc.

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<b>Learning Objectives</b>

• Gain familiarity with various prognostication
tools in acute PE

• Review controversies in management of
intermediate risk PE

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• 66 M presents to ED with abdominal pain

• Similar to past diverticulitis (occasional sharp
“10/10”)

• Last night, became SOB walking up stairs and
passed out, recovered.

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In ED 5 hours

Vital signs

• T 36.8C

• RR 18-26

• HR 86-95

• BP 124-148/66-82

Exam:

• Neg cardiopulm
exam

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• What is the diagnosis and where should he be
admitted?

1. Massive PE—ICU

2. Submassive PE—ICU
3. Submassive PE—Ward
4. Low-risk PE—Ward

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<b>Massive—High Risk</b>

– Sustained hypotension (SBP < 90) for at least 15m or
on inotropes not due to another cause <i>or</i>

– Pulselessnes <i>or </i>

– Profound bradycardia (< 40)

– “Syncope” (perhaps)

– Distinct management pathway

• Acute resuscitation

• Primary reperfusion (lytics, surgery, percutaneous)

• ICU level care

• ECMO

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<b>Submassive—Intermediate Risk</b>

– Acute PE without hypotension but with either

• RV dysfnx

– Dilation

– Elev BNP

– ECG new RBBB or ischemia

• Myocardial necrosis

– Troponins

• Risk/Management uncertainties

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<b>Low-Risk </b>

– Doesn’t fit criteria for massive nor submassive

– Incidental, sub-segmentals

– Short-term mortality ~ 1%

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Most who make it through ED survive

Causes of Death in those 30+ days

• Recurrent PE

• CV collapse

• Bleeding

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Natural History

Most Deaths Occur Before Hospital

• European Union 2004:

– 34% with sudden death

• Olmsted County, MN

– Death at Day O: 23.5% (causal)

36.4% (+incidental)
• Death at Day 30:

– another 5-10%

Heit, Arch Intern Med, 1999

Hospitalized patients
Intermediate risk

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<b>Focus on Submassive/</b>

<b>Intermediate Risk PE:</b>

Risk Stratification

• Why?

• How?

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<b>Submassive PE:</b>

Why Stratify Risk?

• “Close monitoring” for early complications

• Optimize standard Tx (therapeutic heparin)

Smith, Morgenthaler et al, Chest, 2010

• Offer escalation in the case of deterioration

– Assuming we can detect it in time
• ? Reduce long-term complications

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Risk Stratification

• Demographics

• Comorbid illness

• Acute physiologic response markers

• Echocardiography

– RV dysfunction/failure has been seen in low risk sPESI

• Imaging

– Saddle embolism

• Biomarkers

– Troponin, BNP

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<b>PESI</b>

Pulmonary Embolism Severity Index

• 15K+ patients dismissals from 186 PA hospitals

– Data derived from dismissal coding (ICD-9)

• Primary outcome: 30-day mortality

• Prospective ext. validation in 221 inpatients in France/Switz.

• 11 variables predict risk

– Demographic (2)

– Comorbid disease (3)

– Acute clinical findings (6)

– Another 7 lab values were indep associated but didn’t change modeling

• Didn’t include echocardiography, CT findings, biomarkers

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Submassive/Intermediate Risk PE

RV Enlargement/Dysfunction

• Traditionally considered a marker of higher risk

• ~20% mortality rates in older cohorts (1990’s)

<b>Contemporary reassessment—</b>

<b>increasing use of portable echo and CT angio</b>

<b>more common and may not be a marker of high risk</b>

• RV abnormalities are common in hemodynamically stable patients

– 63% by CT measurement

– 23% by echocardiography

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RV Assessment by Echo

• Subjectivity; operator dependent

• Shape defies reliable size assessment

• No agreement on best measure

– Tricuspid annular plane systolic excursion (TAPSE)

– McConnell’s sign—free wall down, apex contracts

• RV infarct mimics PE

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RV Assessment by CT

• Volumetric determination of RVV/LVV ratio is
least user-dependent

• Septal bowing

• IVC reflux of dye

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Predictors of Early (30d) Mortality

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<b>Submassive PE:</b>

Why Stratify Risk?

• “Close monitoring” for early complications

• Optimize standard Tx (therapeutic heparin)

Smith, Morgenthaler et al, Chest, 2010

• Offer escalation in the case of deterioration

– Assuming it’s detected

• ? Reduce long-term complications

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• 1005 pts with RV dysfunction and elevated
troponin but normotensive

• Randomized to heparin with or without
tenecteplase (with option for cross-over)

• Primary outcome: death or hemodynamic

decompensation within 7d of randomization

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• Hemorrhagic stroke: 2.0% vs 0.2%

• Low risk of death from any cause in the heparin

group (1.8%)

• Only 3.4% received rescue thrombolysis for hemodyn
decompensation

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JAMA 2014

• NNT 65, NNH 18

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<b>Submassive PE:</b>

Why Stratify Risk?

• “Close monitoring” for early complications

• Optimize standard Tx (therapeutic heparin)

Smith, Morgenthaler et al, Chest, 2010

• Offer escalation in the case of deterioration

– <i><b>Assuming we see it coming</b></i>

• ? Reduce long-term complications

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• 709 of the original 1,006 patients (28 of 76 sites)

• Followed median 38 mos

• No significant differences in long-term:

– Death since randomization (20 vs. 18%; “low”)

– Functional limitation

– Suggestion of pulm HTN by echo parameters

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76 yo woman

• To ED with acute pleuritic chest pain; h/o
post-operative DVT 3 yrs ago

• PMH: HTN, on lisinopril; OSA, non-adherent to
CPAP

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• BP 108/76; HR 95

• O2 sat 90% RA

• Exam BMI 42; otherwise
unremarkable

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Which of the following excludes this

patient from ED dismissal to home for

treatment of PE?

1. Her age (76 yrs)
2. RV enlargement

3. 90% saturation on RA
4. BMI 42

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<i>ED-to-Home:</i>

Rationale

• Influences:

– high in-patient census numbers

– resource and cost-containment

– The “incidental” PE detected on imaging performed for other
indications

– Anecdotes of the patient that “didn’t need to be admitted”

– More patient-friendly home treatment (DOAC’s)

• An existing ED-to-Home pathway for DVT

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• 344 pts in 19 ED in Europe and US

• Low risk classification (PESI class I and II)

• Up to 5 days SQ LMWH then oral A/C

• Recurrent VTE at 90d (1 vs 0)

• Death at 90d (1 vs 1)

• Young (late 40’s), low rates of Ca (1-2%)

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Risk Stratification: Tools

• Pulmonary Embolism Severity Index (PESI)

– 11 variables to predict risk via a numeric scale

– 5 classes <i>Aujesky, 2005</i>

• sPESI (simplified PESI)

– 6 variables

– Low risk vs. High Risk <i>Jiminez, 2010</i>

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• Ottawa Hospital

– 1,100 bed major teaching hospital

– 50% of PE’s treated as an outpatient, empirically selected

• Seen in Thrombo Clinic within 24 hrs (7 days/wk)

• 2010-15; symptomatic PE, CT confirmed or high-prob V/Q

• Chart review of 576 inpatients vs 506 outpatients (matched)

• Primary outcome: adverse events at 14 days

– Recurrent VTE, major bleeding, death

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A few words about direct oral

anticoagulants (DOACs)

• Not studied in those with BMI > 40

• Contraindicated in valvular disease/prosthesis,
pregnancy, end-stage liver disease

• Other idiosyncracies; reimbursement issues

• Ask Mayo Expert

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