Pulmonary Embolism (PE) is fairly easy when the patient is well. Sicker presentations, however, opens up a host of treatment options. This has led some hospitals to develop Pulmonary Embolism Response Teams (PERT). Is this a good or bad idea–the devil is in the details. If you are making decisions on your own–how should you treat. Today I will discuss these issues and a bunch more!

Print Out These Two Pages

• EMCrit RACC PERT Flow 2021-10-07
• Fibrinolytic Spectrum

Risk Stratification

• sPESI – Patients to have a look at, not to make treatment decisions
• Shock Index is closer to the things I care about [https://www.sciencedirect.com/science/article/abs/pii/S1872931216300151]
• Low SVi quite predictive [Echocardiography-Derived Stroke Volume Index Is Associated With Adverse In-Hospital Outcomes in Intermediate-Risk Acute Pulmonary Embolism: A Retrospective Cohort Study. Chest. 2020 Sep;158(3):1132-1142. doi: 10.1016/j.chest.2020.02.066]
• BOVA is the most applicable score, but works better when lactate is added [27350628] [10.1016/j.ejim.2021.01.021]
• Heart Rate is a huge predictor of badness–adding HR>140 to BOVA increases specificity!!! [PMID: 34478718]
• Need more categories…

Systemic Lytics for PE

Spectrum of Fibrinolytic Use Figure

Go as low as possible (note: there may be genetic and disease-related thrombolytic resistance [e.g. metabolic syndrome])

• The Aykan et al. Abstract of 25 mg over 6 hrs for massive PE [Aykan AC et al. Low dose prolonged infusion of tissue type plasminogen activator therapy in massive pulmonary embolism. European Heart J 2014; 35(Suppl 1): 69.] We got the actual paper published now, please see EMCrit 354 – Reduced-Dose Systemic Peripheral Fibrinolysis in Massive Pulmonary Embolism
• Clinical safety and efficacy of thrombolytic therapy with low-dose prolonged infusion of tissue type plasminogen activator in patients with intermediate-high risk pulmonary embolism

• Safety of low-dose prolonged infusion of tissue plasminogen activator therapy in patients with thromboembolic events in the intensive care unit

Contraindications to Systemic Lysis

AHA Guidelines (Circulation. 2011;123:1788)

Absolute contraindications

• any prior intracranial hemorrhage
• known structural intracranial cerebrovascular disease (eg, arteriovenous malformation)
• known malignant intracranial neoplasm
• ischemic stroke within 3 months
• suspected aortic dissection
• active bleeding or bleeding diathesis,
• recent surgery encroaching on the spinal canal or brain
• recent significant closed-head or facial trauma with radiographic evidence of bony fracture or brain injury

Relative contraindications

• age >75 years
• current use of anticoagulation
• pregnancy
• noncompressible vascular punctures
• traumatic or prolonged cardiopulmonary resuscitation (>10 minutes)
• recent internal bleeding (within 2 to 4 weeks)
• history of chronic, severe, and poorly controlled hypertension
• severe uncontrolled hypertension on presentation (systolic blood pressure >180 mm Hg or diastolic blood pressure >110 mm Hg); dementia
• remote (>3 months) ischemic stroke
• major surgery within 3 weeks.

Recent surgery, depending on the territory involved, and minor injuries, including minor head trauma due to syncope, are not necessarily barriers to fibrinolysis.

The clinician is in the best position to judge the relative merits of fibrinolysis on a case-by-case basis.

EMCrit Version Derived from All the Evidence I Can Gather

Age as a Factor

• > 65 2-fold greater risk of bleed
• > 75 risk is 4-fold

Is tenecteplase safe?

The PEITHO trial had a higher rate of ICH than other PE lytic studies. This has led some to ? whether tenecteplase is as safe as Alteplase. I think the Assent-2 answers this ? resoundingly.

PERT Teams

2-Types of Clinicians in the ED and ICU

Resource, not obligatory for treatment decisions

Stories of transfer for PERT team

Best Uses of PERT Teams are for patients with bleeding risks & for follow-up of borderline patients

Hi-PEITHO Rant

There will be negatives to this trial and yet I cannot condemn anyone involved in it.

Are Catheter Directed Techniques any better than similar dose Systemic Lysis?

A paper in the Anesthesia Lit looked at very low doses (0.5-4 mg) of tPA given via central line for massive intra-op PEs with excellent results, but only 4 pts so don't hang your hat on it [21127275]

Is Ultrasound-Assisted CDT and better than Standard CDT:

• Cost Analysis

Additional New Info

• High-Risk CT Findings with good clinical status do not require Lytics/Intervention
• ECMO for PE [J Vasc Surg Venous Lymphat Disord 2021 Mar;9(2):307-314. doi: 10.1016/j.jvsv.2020.04.033.]
• Great Review on why Unfractionated Heparin is Garbage
• CDL vs. Systemic Lysis (but not reduced dose)
• MA of Systemic Lysis vs. CDT

Other Links on EMCrit

• Podcast 143 – Hemodynamic Management of Massive Pulmonary Embolism (PE)
• Podcast 128 – Pulmonary Embolism Treatment Options and the PEAC Team with Oren Friedman