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 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 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. | ||
==Triage== | ==Triage== | ||
One of the most important aspects in the care of a patient with acute PE is triage or early risk stratification. Patients who are diagnosed with a low-risk PE may require only anticoagulation and medical ward admission, | One of the most important aspects in the care of a patient with acute PE is triage or early risk stratification. | ||
* Patients who are diagnosed with a low-risk PE may require only anticoagulation and medical ward admission. | |||
* On the other hand, patients with massive PE or those with submassive PE who do not improve clinically may benefit from thrombolysis and ICU admission. Initial supportive therapies in these patients may include: | |||
** Respiratory support with oxygen for [[Hypoxemia|hypoxemic]] patients or mechanical [[ventilation]] in cases of severe [[Hypoxemia|hypoxemia]] or [[respiratory failure]]. | |||
** Hemodynamic support with intravenous fluids or intravenous vasopressors for [[hypotensive]] patients. Intravenous fluids should be administered cautiously, as increased right ventricular load can disable the right ventricular oxygen supply-to-demand balance.<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> | |||
==Anticoagulation== | |||
===Initial anticoagulation=== | |||
===Long-term anticoagulation=== | |||
===Extended anticoagulation=== | |||
===Specific circumstances=== | |||
===Newer anticoagulants=== | |||
==Thrombolysis== | |||
==Treatment algorithm== | |||
=== | ==Compression Stockings== | ||
Depending on the clinical presentation, initial therapy is primarily aimed at: | Depending on the clinical presentation, initial therapy is primarily aimed at: | ||
# Restoration of flow through occluded pulmonary arteries, OR | # Restoration of flow through occluded pulmonary arteries, OR | ||
Revision as of 03:29, 8 May 2012
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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Pulmonary embolism (PE) is a potentially lethal condition, with a mortality rate close to 30 percent without treatment. Thus, prompt 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.
Triage
One of the most important aspects in the care of a patient with acute PE is triage or early risk stratification.
- Patients who are diagnosed with a low-risk PE may require only anticoagulation and medical ward admission.
- On the other hand, patients with massive PE or those with submassive PE who do not improve clinically may benefit from thrombolysis and ICU admission. Initial supportive therapies in these patients may include:
- Respiratory support with oxygen for hypoxemic patients or mechanical ventilation in cases of severe hypoxemia or respiratory failure.
- Hemodynamic support with intravenous fluids or intravenous vasopressors for hypotensive patients. Intravenous fluids should be administered cautiously, as increased right ventricular load can disable the right ventricular oxygen supply-to-demand balance.[1]
Anticoagulation
Initial anticoagulation
Long-term anticoagulation
Extended anticoagulation
Specific circumstances
Newer anticoagulants
Thrombolysis
Treatment algorithm
Compression Stockings
Depending on the clinical presentation, initial therapy is primarily aimed at:
- Restoration of flow through occluded pulmonary arteries, OR
- Prevention of potentially fatal early recurrences.
Most common reason for mortality is recurrent PE, occurring within the few hours of the initial event[2]. Anticoagulant therapy decreases mortality by 2% to 8%, thus making it absolutely necessary to start therapy as soon as possible[3].
Majority of the patients should be started on anticoagulation, with one of the following drugs[4][5]:
- Subcutaneous Low molecular weight heparin
- Intravenous unfractionated heparin.
- Factor Xa Inhibitors (Fondaparinux).
Treatment Protocol[6]
Stabilize the patient
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Initial Treatment options (≤5 Days)
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| 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) | |||||||||||||||||||
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 may be stopped because of:
- Risk of bleeding.
- Change in patients preference.
Treatment of choice:Special considerations
- Subcutaneous or Intravenous Low molecular weight heparin.
- Hemodynamically stable patients.
- Thrombolysis
- High Risk Hemodynamically stable patients.
- Hemodynamically Unstable patients.
- Percutaneous mechanical thrombectomy.
- High risk patients with absolute contraindications to Thrombolytics.
- Patients with failed Thrombolysis.
- Low molecular weight heparin is preferred over Vitamin K antagonist.
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 shows clinical improvement | |||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||
| Surgical emblectomy or catheter based interventions | Continue anticoagulation | ||||||||||||||||||||||||||||||||||||
References
- ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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.
- ↑ 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.
- ↑ Agnelli G, Becattini C (2010). "Acute pulmonary embolism". N Engl J Med. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294.