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Risk-adapted management of acute pulmonary embolism: recent evidence, new guidelines.

Käberich A, Wärntges S, Konstantinides S - Rambam Maimonides Med J (2014)

Bottom Line: Venous thromboembolism (VTE), the third most frequent acute cardiovascular syndrome, may cause life-threatening complications and imposes a substantial socio-economic burden.Recently published European Guidelines emphasize the importance of clinical prediction rules in combination with imaging procedures (assessment of right ventricular function) and laboratory biomarkers (indicative of myocardial stress or injury) for identification of normotensive PE patients at intermediate risk for an adverse short-term outcome.In this patient group, systemic full-dose thrombolysis was associated with a significantly increased risk of intracranial bleeding, a complication which discourages its clinical application unless hemodynamic decompensation occurs.

View Article: PubMed Central - PubMed

Affiliation: Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.

ABSTRACT
Venous thromboembolism (VTE), the third most frequent acute cardiovascular syndrome, may cause life-threatening complications and imposes a substantial socio-economic burden. During the past years, several landmark trials paved the way towards novel strategies in acute and long-term management of patients with acute pulmonary embolism (PE). Risk stratification is increasingly recognized as a cornerstone for an adequate diagnostic and therapeutic management of the highly heterogeneous population of patients with acute PE. Recently published European Guidelines emphasize the importance of clinical prediction rules in combination with imaging procedures (assessment of right ventricular function) and laboratory biomarkers (indicative of myocardial stress or injury) for identification of normotensive PE patients at intermediate risk for an adverse short-term outcome. In this patient group, systemic full-dose thrombolysis was associated with a significantly increased risk of intracranial bleeding, a complication which discourages its clinical application unless hemodynamic decompensation occurs. A large-scale clinical trial program evaluating new oral anticoagulants in the initial and long-term treatment of venous thromboembolism showed at least comparable efficacy and presumably increased safety of these drugs compared to the current standard treatment. Research is continuing on catheter-directed, ultrasound-assisted, local, low-dose thrombolysis in the management of intermediate-risk PE.

No MeSH data available.


Related in: MedlinePlus

Risk-Adjusted Management Strategies in Acute PE. Based on Konstantinides et al.8a If echocardiography has already been performed during diagnostic work-up for PE and detected RV dysfunction, or if the CT already performed for diagnostic work-up has shown RV enlargement (right/left ventricular ratio ≥0.9), a cardiac troponin test should be performed except for cases in which primary reperfusion is not a therapeutic option (e.g. due to severe co-morbidity or limited life expectancy of the patient).b Markers of myocardial injury (e.g. elevated cardiac troponin I or -T concentrations in plasma) or of heart failure as a result of (right) ventricular dysfunction (elevated natriuretic peptide concentrations in plasma). If a laboratory test for a cardiac biomarker has already been performed during initial diagnostic work-up (e.g. in the chest pain unit) and was positive, then an echocardiogram should be considered to assess RV function, or RV size should be (re)assessed on CT.c Patients in the PESI Class I–II, or with sPESI of 0, and elevated cardiac biomarkers or signs of RV dysfunction on imaging tests are also to be classified into the intermediate-to-low-risk category. This might apply to situations in which imaging or biomarker results become available before calculation of the clinical severity index. These patients are probably not candidates for home treatment.d Thrombolysis, if (and as soon as) clinical signs of hemodynamic decompensation appear; surgical pulmonary embolectomy or percutaneous catheter-directed treatment may be considered as alternative options to systemic thrombolysis, particularly if the bleeding risk is high.e Monitoring should be considered for patients with confirmed PE and a positive troponin test, even if there is no evidence of RV dysfunction on echocardiography or CT.f The simplified version of the PESI has not been validated in prospective home treatment trials; inclusion criteria other than the PESI were used in two single-armed (non-randomized) management studies.A/C, anticoagulation; CT, computed tomographic pulmonary angiography; PE, pulmonary embolism; PESI, pulmonary embolism severity index; RV, right ventricular; sPESI, simplified pulmonary embolism severity index.
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f3-rmmj-5-4-e0040: Risk-Adjusted Management Strategies in Acute PE. Based on Konstantinides et al.8a If echocardiography has already been performed during diagnostic work-up for PE and detected RV dysfunction, or if the CT already performed for diagnostic work-up has shown RV enlargement (right/left ventricular ratio ≥0.9), a cardiac troponin test should be performed except for cases in which primary reperfusion is not a therapeutic option (e.g. due to severe co-morbidity or limited life expectancy of the patient).b Markers of myocardial injury (e.g. elevated cardiac troponin I or -T concentrations in plasma) or of heart failure as a result of (right) ventricular dysfunction (elevated natriuretic peptide concentrations in plasma). If a laboratory test for a cardiac biomarker has already been performed during initial diagnostic work-up (e.g. in the chest pain unit) and was positive, then an echocardiogram should be considered to assess RV function, or RV size should be (re)assessed on CT.c Patients in the PESI Class I–II, or with sPESI of 0, and elevated cardiac biomarkers or signs of RV dysfunction on imaging tests are also to be classified into the intermediate-to-low-risk category. This might apply to situations in which imaging or biomarker results become available before calculation of the clinical severity index. These patients are probably not candidates for home treatment.d Thrombolysis, if (and as soon as) clinical signs of hemodynamic decompensation appear; surgical pulmonary embolectomy or percutaneous catheter-directed treatment may be considered as alternative options to systemic thrombolysis, particularly if the bleeding risk is high.e Monitoring should be considered for patients with confirmed PE and a positive troponin test, even if there is no evidence of RV dysfunction on echocardiography or CT.f The simplified version of the PESI has not been validated in prospective home treatment trials; inclusion criteria other than the PESI were used in two single-armed (non-randomized) management studies.A/C, anticoagulation; CT, computed tomographic pulmonary angiography; PE, pulmonary embolism; PESI, pulmonary embolism severity index; RV, right ventricular; sPESI, simplified pulmonary embolism severity index.

Mentions: Venous thromboembolism has received relatively little attention from the scientific and medical community for decades. Recently, however, advances in diagnostic imaging, along with the development of new antithrombotic agents and strategies, increased awareness of the importance of VTE and began to improve patient outcomes in the acute phase and over the long term. The new evidence that accumulated in all these areas has led to clear-cut, clinical practice-relevant recommendations which are included in the recently updated ESC Guidelines on the management of acute pulmonary embolism (Figure 3).8


Risk-adapted management of acute pulmonary embolism: recent evidence, new guidelines.

Käberich A, Wärntges S, Konstantinides S - Rambam Maimonides Med J (2014)

Risk-Adjusted Management Strategies in Acute PE. Based on Konstantinides et al.8a If echocardiography has already been performed during diagnostic work-up for PE and detected RV dysfunction, or if the CT already performed for diagnostic work-up has shown RV enlargement (right/left ventricular ratio ≥0.9), a cardiac troponin test should be performed except for cases in which primary reperfusion is not a therapeutic option (e.g. due to severe co-morbidity or limited life expectancy of the patient).b Markers of myocardial injury (e.g. elevated cardiac troponin I or -T concentrations in plasma) or of heart failure as a result of (right) ventricular dysfunction (elevated natriuretic peptide concentrations in plasma). If a laboratory test for a cardiac biomarker has already been performed during initial diagnostic work-up (e.g. in the chest pain unit) and was positive, then an echocardiogram should be considered to assess RV function, or RV size should be (re)assessed on CT.c Patients in the PESI Class I–II, or with sPESI of 0, and elevated cardiac biomarkers or signs of RV dysfunction on imaging tests are also to be classified into the intermediate-to-low-risk category. This might apply to situations in which imaging or biomarker results become available before calculation of the clinical severity index. These patients are probably not candidates for home treatment.d Thrombolysis, if (and as soon as) clinical signs of hemodynamic decompensation appear; surgical pulmonary embolectomy or percutaneous catheter-directed treatment may be considered as alternative options to systemic thrombolysis, particularly if the bleeding risk is high.e Monitoring should be considered for patients with confirmed PE and a positive troponin test, even if there is no evidence of RV dysfunction on echocardiography or CT.f The simplified version of the PESI has not been validated in prospective home treatment trials; inclusion criteria other than the PESI were used in two single-armed (non-randomized) management studies.A/C, anticoagulation; CT, computed tomographic pulmonary angiography; PE, pulmonary embolism; PESI, pulmonary embolism severity index; RV, right ventricular; sPESI, simplified pulmonary embolism severity index.
© Copyright Policy
Related In: Results  -  Collection

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Show All Figures
getmorefigures.php?uid=PMC4222429&req=5

f3-rmmj-5-4-e0040: Risk-Adjusted Management Strategies in Acute PE. Based on Konstantinides et al.8a If echocardiography has already been performed during diagnostic work-up for PE and detected RV dysfunction, or if the CT already performed for diagnostic work-up has shown RV enlargement (right/left ventricular ratio ≥0.9), a cardiac troponin test should be performed except for cases in which primary reperfusion is not a therapeutic option (e.g. due to severe co-morbidity or limited life expectancy of the patient).b Markers of myocardial injury (e.g. elevated cardiac troponin I or -T concentrations in plasma) or of heart failure as a result of (right) ventricular dysfunction (elevated natriuretic peptide concentrations in plasma). If a laboratory test for a cardiac biomarker has already been performed during initial diagnostic work-up (e.g. in the chest pain unit) and was positive, then an echocardiogram should be considered to assess RV function, or RV size should be (re)assessed on CT.c Patients in the PESI Class I–II, or with sPESI of 0, and elevated cardiac biomarkers or signs of RV dysfunction on imaging tests are also to be classified into the intermediate-to-low-risk category. This might apply to situations in which imaging or biomarker results become available before calculation of the clinical severity index. These patients are probably not candidates for home treatment.d Thrombolysis, if (and as soon as) clinical signs of hemodynamic decompensation appear; surgical pulmonary embolectomy or percutaneous catheter-directed treatment may be considered as alternative options to systemic thrombolysis, particularly if the bleeding risk is high.e Monitoring should be considered for patients with confirmed PE and a positive troponin test, even if there is no evidence of RV dysfunction on echocardiography or CT.f The simplified version of the PESI has not been validated in prospective home treatment trials; inclusion criteria other than the PESI were used in two single-armed (non-randomized) management studies.A/C, anticoagulation; CT, computed tomographic pulmonary angiography; PE, pulmonary embolism; PESI, pulmonary embolism severity index; RV, right ventricular; sPESI, simplified pulmonary embolism severity index.
Mentions: Venous thromboembolism has received relatively little attention from the scientific and medical community for decades. Recently, however, advances in diagnostic imaging, along with the development of new antithrombotic agents and strategies, increased awareness of the importance of VTE and began to improve patient outcomes in the acute phase and over the long term. The new evidence that accumulated in all these areas has led to clear-cut, clinical practice-relevant recommendations which are included in the recently updated ESC Guidelines on the management of acute pulmonary embolism (Figure 3).8

Bottom Line: Venous thromboembolism (VTE), the third most frequent acute cardiovascular syndrome, may cause life-threatening complications and imposes a substantial socio-economic burden.Recently published European Guidelines emphasize the importance of clinical prediction rules in combination with imaging procedures (assessment of right ventricular function) and laboratory biomarkers (indicative of myocardial stress or injury) for identification of normotensive PE patients at intermediate risk for an adverse short-term outcome.In this patient group, systemic full-dose thrombolysis was associated with a significantly increased risk of intracranial bleeding, a complication which discourages its clinical application unless hemodynamic decompensation occurs.

View Article: PubMed Central - PubMed

Affiliation: Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.

ABSTRACT
Venous thromboembolism (VTE), the third most frequent acute cardiovascular syndrome, may cause life-threatening complications and imposes a substantial socio-economic burden. During the past years, several landmark trials paved the way towards novel strategies in acute and long-term management of patients with acute pulmonary embolism (PE). Risk stratification is increasingly recognized as a cornerstone for an adequate diagnostic and therapeutic management of the highly heterogeneous population of patients with acute PE. Recently published European Guidelines emphasize the importance of clinical prediction rules in combination with imaging procedures (assessment of right ventricular function) and laboratory biomarkers (indicative of myocardial stress or injury) for identification of normotensive PE patients at intermediate risk for an adverse short-term outcome. In this patient group, systemic full-dose thrombolysis was associated with a significantly increased risk of intracranial bleeding, a complication which discourages its clinical application unless hemodynamic decompensation occurs. A large-scale clinical trial program evaluating new oral anticoagulants in the initial and long-term treatment of venous thromboembolism showed at least comparable efficacy and presumably increased safety of these drugs compared to the current standard treatment. Research is continuing on catheter-directed, ultrasound-assisted, local, low-dose thrombolysis in the management of intermediate-risk PE.

No MeSH data available.


Related in: MedlinePlus