Pulmonary embolism treatment approach: Difference between revisions

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==Overview==
==Overview==
'''Pulmonary embolism''' (PE) is a potentially lethal condition, with a mortality rate close to 30 percent without treatment. Thus prompt and effective therapy is of utmost important. In most cases, [[anticoagulant]] therapy is the mainstay of treatment. Acutely, supportive treatments, such as [[oxygen]] or [[analgesia]], are often required.
'''Pulmonary embolism''' (PE) is a potentially lethal condition, with a mortality rate close to 30 percent without treatment. Thus prompt and effective therapy is of utmost important. In most cases, [[anticoagulant]] therapy is the mainstay of treatment. Acutely, supportive treatments, such as [[oxygen]] or [[analgesia]], are often required.
==Initial Treatment==
Most common reason for mortality is recurrent PE, occurring within the few hours of the initial event<ref name="pmid1560799">{{cite journal |author=Carson JL, Kelley MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, Schwartz JS, Thompson BT, Popovich J, Hobbins TE |title=The clinical course of pulmonary embolism |journal=N. Engl. J. Med. |volume=326 |issue=19 |pages=1240–5 |year=1992 |month=May |pmid=1560799 |doi=10.1056/NEJM199205073261902 |url=http://dx.doi.org/10.1056/NEJM199205073261902 |accessdate=2011-12-12}}</ref>. Anticoagulant therapy decreases mortality by 2% to 8%, thus making it absolutely necessary to start therapy as soon as possible<ref name="pmid10227218">{{cite journal |author=Goldhaber SZ, Visani L, De Rosa M |title=Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER) |journal=Lancet |volume=353 |issue=9162 |pages=1386–9 |year=1999 |month=April |pmid=10227218 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673698075345 |accessdate=2011-12-12}}</ref>.
Majority of patient should be started on anticoagulation, with one of the following drugs<ref name="pmid18574272">{{cite journal| author=Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ et al.| title=Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). | journal=Chest | year= 2008 | volume= 133 | issue= 6 Suppl | pages= 454S-545S | pmid=18574272 | doi=10.1378/chest.08-0658 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18574272  }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>:
*Subcutaneous [[low molecular weight heparin|Low molecular weight heparin]]
*Intravenous [[unfractionated heparin]].
*Factor Xa Inhibitors ([[Fondaparinux]]).
==Treatment Protocol<ref name="pmid20592294">{{cite journal| author=Agnelli G, Becattini C| title=Acute pulmonary embolism. | journal=N Engl J Med | year= 2010 | volume= 363 | issue= 3 | pages= 266-74 | pmid=20592294 | doi=10.1056/NEJMra0907731 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20592294  }} </ref>==
{{familytree/start |summary=PE Pathophysiology.}}
{{familytree | | | | | | | | A01| A01='''Stabilize the patient'''
*Respiratory Support
*Hemodynamic Support
*Anticoagulation}}
{{familytree | | | | | | | |!|}}
{{familytree | | | | | | | | GMa|GMa='''Initial Treatment (≤5 Days)'''
*[[unfractionated heparin|Unfractionated heparin]]
*[[Low molecular weight heparin|Low molecular weight heparin]]
*Factor Xa Inhibitors ([[fondaparinux]])
*[[Thrombolysis]]
*[[Pulmonary thrombectomy|Percutaneous mechanical embolectomy]]
*Surgery
*[[Vitamin K antagonist|Vitamin K antagonists]]}}
{{familytree | | | | | | | |!|}}
{{familytree | | | | | | | | A01| A01='''Long Term Treatment (≥3 Month)'''
*[[Vitamin K antagonist|Vitamin K antagonists]]
(INR target, 2.0-3.0)}}
{{familytree | | | | | | | |!|}}
{{familytree | | | | | | | | SON| SON='''Extended Treatment (Indefinite)'''
*[[Vitamin K antagonist|Vitamin K antagonists]]
(INR target, 2.0-3.0 OR 1.5-1.9)}}
{{familytree/end}}
'''Respiratory Support'''
*Oxygen should be used in [[Hypoxemia|hypoxemic]] patients.
*In cases of severe [[Hypoxemia|hypoxemia]] or [[respiratory failure]], mechanical [[ventilation]] and [[intubation]] should be started.
'''Hemodynamic Support'''<ref name="pmid10199533">{{cite journal |author=Mercat A, Diehl JL, Meyer G, Teboul JL, Sors H |title=Hemodynamic effects of fluid loading in acute massive pulmonary embolism |journal=Crit. Care Med. |volume=27 |issue=3 |pages=540–4 |year=1999 |month=March |pmid=10199533 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0090-3493&volume=27&issue=3&spage=540 |accessdate=2011-12-12}}</ref>
*Intravenous fluid administration is first-line therapy in [[hypotensive]] patients.
*IV Fluid should be administered cautiously, as increase Right ventricular load can disable Right ventricular oxygen supply-to-demand balance.
*If the hemodynamic status fails to improve, then intravenous vasopressors should be considered.
'''Extended Treatment''' should be considered in patients with:
# Active Cancer.
# Unprovoked Pulmonary embolism.
# Recurrent venous thromboembolism.
'''Indefinite treatment''' refers to continued anticoagulation without a pre-scheduled stop date.
Anticoaulation is stopped because of:
# Risk of bleeding.
# Change in patients preference.
===Treatment of Choice:Special Considerations===
* [[Subcutaneous]] or [[Intravenous]] [[LMWH|Low molecular weight heparin]].
**Hemodynamically stable patients.
* [[Thrombolysis]]
**High Risk Hemodynamically stable patients.
**Hemodynamically Unstable patients.
*[[Pulmonary thrombectomy|Percutaneous mechanical thrombectomy]].
**High risk patients with absolute [[Thrombolysis#Contradictions|contraindications]] to Thrombolytics.
**Patients with failed Thrombolysis.
*[[LMWH|Low molecular weight heparin]] is preferred over [[Vitamin K antagonist]].
**[[Cancer]] patients.
**[[Pregnancy|Pregnant]] patients.


==Treatment Algorithm==
==Treatment Algorithm==

Revision as of 19:55, 21 December 2011

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editors-in-Chief: Ujjwal Rastogi, MBBS [2]

Overview

Pulmonary embolism (PE) is a potentially lethal condition, with a mortality rate close to 30 percent without treatment. Thus prompt and effective therapy is of utmost important. In most cases, anticoagulant therapy is the mainstay of treatment. Acutely, supportive treatments, such as oxygen or analgesia, are often required.

Initial Treatment

Most common reason for mortality is recurrent PE, occurring within the few hours of the initial event[1]. Anticoagulant therapy decreases mortality by 2% to 8%, thus making it absolutely necessary to start therapy as soon as possible[2].

Majority of patient should be started on anticoagulation, with one of the following drugs[3][4]:

Treatment Protocol[5]

 
 
 
 
 
 
 
Stabilize the patient
  • Respiratory Support
  • Hemodynamic Support
  • Anticoagulation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial Treatment (≤5 Days)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Long Term Treatment (≥3 Month) (INR target, 2.0-3.0)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Extended Treatment (Indefinite) (INR target, 2.0-3.0 OR 1.5-1.9)

Respiratory Support

Hemodynamic Support[6]

  • Intravenous fluid administration is first-line therapy in hypotensive patients.
  • IV Fluid should be administered cautiously, as increase Right ventricular load can disable Right ventricular oxygen supply-to-demand balance.
  • If the hemodynamic status fails to improve, then intravenous vasopressors should be considered.

Extended Treatment should be considered in patients with:

  1. Active Cancer.
  2. Unprovoked Pulmonary embolism.
  3. Recurrent venous thromboembolism.

Indefinite treatment refers to continued anticoagulation without a pre-scheduled stop date. Anticoaulation is stopped because of:

  1. Risk of bleeding.
  2. Change in patients preference.

Treatment of Choice:Special Considerations

Treatment Algorithm

 
 
 
 
 
 
 
Stabilize the patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is anticoagulation contraindicated ?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic evaluation
 
 
 
 
 
 
 
Anticoagulate with SC LMWH or IV UFH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PE excluded
 
PE confirmed
 
 
 
 
 
Diagnostic evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No further Treatment
 
Inferior vena cava filter
 
 
PE excluded
 
PE confirmed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discontinue Anticoagulants
 
Clinicaly severe enough to need Thrombolysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is thrombolytic Contraindicated?
 
Continue Anticoagulants
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical emblectomy or catheter based interventions
 
Hold Anticoagulation, Give Thrombolytics then resume Anticoagulations
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient show Clinically Improvement
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical emblectomy or catheter based interventions
 
Continue Anticoagulation

Template:WH Template:WS

  1. ↑ Carson JL, Kelley MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, Schwartz JS, Thompson BT, Popovich J, Hobbins TE (1992). "The clinical course of pulmonary embolism". N. Engl. J. Med. 326 (19): 1240–5. doi:10.1056/NEJM199205073261902. PMID 1560799. Retrieved 2011-12-12. Unknown parameter |month= ignored (help)
  2. ↑ Goldhaber SZ, Visani L, De Rosa M (1999). "Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER)". Lancet. 353 (9162): 1386–9. PMID 10227218. Retrieved 2011-12-12. Unknown parameter |month= ignored (help)
  3. ↑ Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ; et al. (2008). "Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 454S–545S. doi:10.1378/chest.08-0658. PMID 18574272.
  4. ↑ Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
  5. ↑ Agnelli G, Becattini C (2010). "Acute pulmonary embolism". N Engl J Med. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294.
  6. ↑ Mercat A, Diehl JL, Meyer G, Teboul JL, Sors H (1999). "Hemodynamic effects of fluid loading in acute massive pulmonary embolism". Crit. Care Med. 27 (3): 540–4. PMID 10199533. Retrieved 2011-12-12. Unknown parameter |month= ignored (help)
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