Podcast 552: PE Management and Risk Stratification

Contributor: Dylan Luyten, MD

Educational Pearls:

• After you diagnose a pulmonary embolism (PE) via CT or VQ scan, we need to categorize the PE as massive, sub-massive, or just PE to dictate treatment.  
• Massive PE: shock with hypotension due to an embolism, and the treatment of choice is thrombolysis with IV tPA with anticoagulation after lysis. Catheter thrombolysis is not used in the hemodynamically unstable patient but can be done after they are stable.
• Sub-massive: signs of right heart strain/failure but hemodynamically stable. This can be EKG changes, positive biomarkers, or imaging findings. These patients can be treated with IV heparin as there may benefit from catheter directed thrombolysis which has been shown to lead to better functional outcomes.  
• Everything else can be stratified to determine whether inpatient even outpatient treatment is necessary 
• Pulmonary Embolism Severity Index (PESI) or Hestia criteria and can help determine if the patient is better suited for in or outpatient management.
• Non massive or sub-massive PEs are treated with heparin/Lovenox bridged to Warfarin, a factor Xa inhibitor (ex. Xarelto), or direct oral anticoagulants (DOAC).

Editor's note: intravenous heparin is preferable to other anticoagulants when considering interventional radiology as it can be shut off and/or reversed if necessary prior to procedure

References

1. Sista, A. et al. Stratification, Imaging, and Management of Acute Massive and Submassive Pulmonary Embolism. 2017 Jul;284(1):5-24

2. Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, Roy PM, Fine MJ. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005 Oct 15;172(8):1041-6

3. Jimenez, D. et al. Risk stratification of patients with acute symptomatic pulmonary embolism. Intern Emerg Med. 2016 Feb;11(1):11-8.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD