Welcome to the first episode of PERTCast, the official podcast of the PERT Consortium!
Episode 1: Oren Friedman interviews Vic Tapson about risk stratification of the pulmonary embolism patient.
Oren Friedman MD
Associate Director, Cardiac Surgery ICU
Pulmonary Critical Care
Cedars-Sinai Medical Center
Victor Tapson MD
Professor of Medicine
Director, Venous Thromboembolism and Pulmonary Vascular Disease Research Program
Associate Director, Pulmonary and Critical Care Section
Cedars-Sinai Medical Center
PE risk stratification Pearls: history and classifications.
- Patient's appearance and vitals (initial and trend) are most important parts of risk stratification algorithm.
- Syncope can have a wide differential. Syncope in setting of PE can have significant consequences.
- Patient resting comfortably can be reassuring, but at the same time ask- what happens on exertion, to gauge the severity of symptoms (i.e. dizziness, near syncope etc.)
- Profound hypoxemia is under recognized in PE classification.
- European Society of Cardiology (ESC) integrates PESI, and sPESI score that is much more practical way of PE classification.
- ESC classification divide PE into Intermediate PE (Submassive PE) in to two categories- Intermediate high risk (positive sPESI score, RV dysfunction and biomarker positivity) or Intermediate low risk (Positive sPESI score, and RV dysfunction or biomarker positivity).
- PE classification is heterogeneous, patient's hemodynamics can evolve, so will be their risk stratification score.
Biomarkers in PE risk stratification:
- Troponin more sensitive than BNP. Be careful for false positives (elevated BNP in chronic heart failure)
- Lactic acid can provide prognostic information in setting of PE.
CTA based risk stratification:
- Contrast reflux into IVC/Liver
- RV/LV ratio >0.9
- Clot burden, 40% occlusion of pulmonary circulation can be associated with high PE related mortality.
Echo based risk stratification:
- Normal RV can't generate systolic pressure in the excess of 50-60 mm Hg.
- Elevated PA systolic pressure >70-80 mm HG suggest chronic component of RV failure
- RV need to have good systolic function to generate high PA pressure
- TAPSE is not the holy grail of RV dysfunction, interpret with caution.
Residual DVT
- Extensive DVT (above knee) with higher risk PE have worse outcomes.
- Patient activity (few days to weeks) should be restricted.
- IVC filter should not be considered in every case of PE with DVT.
Treatment Pearls:
- Every patient with acute PE should be promptly anticoagulated.
- Change in vital trends or persistently abnormal vital signs may help in consideration of advance reperfusion strategies in same PE category.
Take home message:
- Look at patient's appearance + Vitals (HR, RR) and add other objective measures (sPESI, Biomarkers, imaging) + Residual clot burden in risk stratification.
- Activate the multidisciplinary PERT to leverage input from local experts.
References:
- Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35(43):3033-69, 3069a-3069k.
- Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383-9.
- Van der meer RW, Pattynama PM, Van strijen MJ, et al. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology. 2005;235(3):798-803.
- Prandoni P, Lensing AW, Prins MH, et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016;375(16):1524-1531.
- Becattini C, Cohen AT, Agnelli G, et al. Risk Stratification of Patients With Acute Symptomatic Pulmonary Embolism Based on Presence or Absence of Lower Extremity DVT: Systematic Review and Meta-analysis. Chest. 2016;149(1):192-200.
- Grau E, Tenías JM, Soto MJ, et al. D-dimer levels correlate with mortality in patients with acute pulmonary embolism: Findings from the RIETE registry. Crit Care Med. 2007;35(8):1937-41.
