May 18, 2016

There is a Lot More to Know About Managing Pulmonary Emboli

Michael R. Jaff, DO, and Kenneth Rosenfield, MD

Vascular Medicine, Massachusetts General Hospital, Boston

We know a lot about pulmonary emboli (PE). We know that that, though the risk for PE increases with each decade over the age of 40 (1), there is no adult patient population that is immune to the potentially devastating manifestations of PE. From a recent review of the risk of venous thromboemboli during or following prolonged air travel, we know that patients with one or more risk factors for PE should wear graduated compression stockings, avoid dehydration and be considered for pharmacoprophylaxis (2).

From the guidelines of our medical societies, we have recommendations for treatment of PE in many scenarios. For example, the American College of Chest Physicians recently updated its guidelines to recommend systemic thrombolytic therapy over catheter-based therapy for patients with only PE and hypotension (3), and the European Society of Cardiology recommends “primary reperfusion” for the treatment of PE patients at high- and intermediate-high risk (4). Recent data support the use of systemic thrombolytic therapy for PE (5). We’ve learned so much that today there is little debate about the management of hemodynamically stable, minimally symptomatic PE patients. For these patients, the only controversy is which anticoagulant is most appropriate.

So, yes, we know a lot. Unfortunately, there’s a lot we still need to learn.

PERT 2015

For starters, we don’t know the best treatment for “submassive” or “massive” PE. The options for treating these patients are almost as numerous as the opinions of the specialists who contribute to managing these conditions. We know about the challenges: bleeding risk; the often devastating impact of PE on long-term survival; the costs associated with advanced PE therapies; and that our institutions, many of them already stretched thin, struggle to identify patients who might have PE and then to perform rapid and definitive tests and treatments for those who present during “off-hours.”

From our successes with acute myocardial infarction (STEMI) and stroke teams, we know that the key to successfully reducing morbidity and mortality from PE likely lies in learning how to improve our systems so that we rapidly deploy the right team of providers at the right time. Pulmonary Embolus Response Teams (PERT) have been described as a means to achieve that goal (6), and data regarding patient management within an institution offering care through such teams has been published (7).

Pert 2015 2

However, as skeptics have suggested, we don’t know enough about the costs of running PERT programs. We don’t yet know if risks ensue when such programs are dominated by specialists who perform PE interventions. Despite the demonstrated benefits of acute stroke and STEMI teams, we don’t yet have enough data to confirm the value of PERT programs.

Again, there’s a lot we don’t know, and therefore, there’s a lot for us to debate. If you manage PE patients, please join us at the Massachusetts General Fireman Vascular CME Symposium on Pulmonary Embolism on June 28-29, 2016. There, you will see world-renowned experts coming come together to examine what we know and what we don’t know, and to debate the knowledge gaps and how best to fill them.

Yes, there’s a lot we don’t know about this all-too-common and potentially deadly condition. Let’s change that. Visit www.pertconsortium.org.

REFERENCES

  1. Raskob GE, Angchaisuksiri P, Blanco AN, et al. Thrombosis: a major contributor to global disease burden. Arterioscler Thromb Vasc Biol 2014;34:2363-71.
  2. Philbrick JT, Shumate R, Siadaty MS, Becker DM. Air travel and venous thromboembolism: a systematic review. J Gen Intern Med 2007;22:107-114.
  3. Kearon C, Aki EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST Guideline and expert panel report. Chest 2016;149:315-52.
  4. Konstantinides SV, Torbick A, Agnelli G, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. 2014;33:3033-80.
  5. Chatterjee S, Chakraborty A, Weinberg I, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage. A meta-analysis.  JAMA 2014;311:2414-21.
  6. Kabrhel C, Jaff MR, Channick R, Baker J, Rosenfield K. A multidisciplinary pulmonary embolism response team. Chest 2013;144:1738-9.
  7. Kabhrel C, Rosovsky R, Channick R, et al. A multispecialty pulmonary embolism response team (PERT)—initial 30-month experience with a novel approach to delivery of care to patients with sub-massive and massive PE. Chest 2016;March 19. ePub ahead of print.