Management of Pulmonary Embolism

Management of Massive & Submassive Pulmonary Embolism

View more PowerPoint from Sun YaiCheng

Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension

Circulation 2011, 123:1788-1830

 

Definition

I.   Massive PE

Acute PE with with at least 1 of the following:

1.  Sustained hypotension

SBP <90 mmHg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or LV dysfunction

2. Pulselessness

3. Persistent profound bradycardia

heart rate <40 bpm with signs or symptoms of shock

II.  Submassive PE

Acute PE without systemic hypotension (SBP >90 mm Hg) but with either RV dysfunction or myocardial necrosis.

1. RV dysfunction means the presence of at least 1 of the following:

• Echo: RV dilation (apical 4-chamber RV diameter divided by LV diameter >0.9), or RV systolic dysfunction
• CT: RV dilation (4-chamber RV diameter divided by LV diameter > 0.9)
• BNP > 90 pg/mL or N-terminal pro-BNP > 500 pg/mL
• ECG changes: New complete or incomplete RBBB, anteroseptal ST elevation or depression, or anteroseptal T-wave inversion

2. Myocardial necrosis is defined as either of the following:

• Troponin I > 0.4 ng/mL, or Troponin T > 0.1 ng/mL

I. Low-Risk PE

Acute PE and the absence of the clinical markers of adverse prognosis that define massive or submassive PE.

Therapy

Recommendations for Embolectomy

• for patients with massive PE and contraindications to fibrinolysis
• for patients with massive PE who remain unstable after receiving fibrinolysis
• for patients with submassive acute PE judged to have clinical evidence of adverse prognosis (new hemodynamic instability, worsening respiratory failure, severe RV dysfunction, or major myocardial necrosis)
• Not recommended for patients with low-risk PE or submassive acute PE with minor RV dysfunction, minor myocardial necrosis, and no clinical worsening