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Risk stratification essential for acute PE

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HOLLYWOOD, Fla. — The presentation of acute pulmonary embolism varies, and risk stratification of patients is essential to achieve optimal outcomes, a speaker said at the International Symposium on Endovascular Therapy.

Catheter-based therapy may be most appropriate for patients with massive PE who are stable or already on extracorporeal membrane oxygenation and patients with high-risk submassive PE, said Victor F. Tapson, MD, FCCP, FRCP, professor of medicine, pulmonary and critical care at Cedars-Sinai.

The standard treatment for PE is anticoagulation, but mortality risk increases with severity of PE, so clinicians must be aware of where each patient stands on the risk curve to make the best decision about adding endovascular or surgical therapy, he said. For example, mortality is 11-fold higher for patients with PE with an obstructive index > 40% who are treated with anticoagulation only.

Victor F. Tapson

Those with submassive PE, generally considered at intermediate risk, are some of the toughest for which to determine the best approach, according to Tapson.

Submassive PE is defined as patients with no hypotension or shock and a simplified Pulmonary Embolism Severity Index score > 0, he said. Those at higher risk within that group also have right ventricular dysfunction and elevated BNP or troponin levels, whereas those at lower risk within that group have one or none of those criteria or a simplified Pulmonary Embolism Severity Index score of 0 but RV dysfunction and at least one elevated biomarker, according to Tapson.

According to European guidelines, for patients with high-risk submassive PE, systemic thrombolysis is not recommended as routine first-line therapy but may be considered if the patient has hemodynamic decompensation, and surgical embolectomy or catheter-directed thrombolysis may be considered when hemodynamic decompensation is imminent and bleeding risk is too high to consider systemic thrombolysis, he said.

Some data suggest that low-risk patients do not benefit from any treatment other than anticoagulation, Tapson said.

The American College of Chest Physicians recommends that catheter-assisted thrombus removal may be appropriate in patients with acute PE associated with hypotension who have high bleeding risk, a failed systemic thrombolysis or shock likely to be fatal before systemic thrombolysis can take effect, Tapson said.

Only one randomized trial of catheter-directed therapy in this population has been conducted, which “is not enough,” he said.

“There are a lot of things we have to take into account when treating patients, not just RV function,” Tapson said. – by Erik Swain

Reference:

Tapson VF. Changing therapies for pulmonary embolism and massive large vein occlusions. Presented at: International Symposium on Endovascular Therapy; Feb. 4-8, 2017; Hollywood, Fla.

Disclosure: Tapson reports consulting for Angiodynamics, Bayer, EKOS/BTG, Inari, Janssen and Portola; receiving research funding from Bayer, BiO2 Medical, Daiichi Sankyo, EKOS/BTG, Inari, Janssen and Portola; and speaking for EKOS/BTG and Janssen.