Case Conference: Submassive PE

by Bob Stuntz in ,


It's no mystery, this patient has a PE.  But the real question is, how do you treat it?  Anticoagulation alone?  Do you give lytics?  We go through the evidence and discuss why you should be strongly considering lytics in your patients with submassive PE. 

  • Definition
    • Massive PE: Acute PE with sustained hypotension (SBP < 90 mmHg x 15 minutes, or requiring inotropic support, and not caused by another source of hypotension), pulselessness, or sustained bradycardia < 40/min with signs of shock
    • Submassive PE: Acute PE without systemic hypotension but either RV dysfunction or myocardial necrosis
      • RV dysfunction
        • RV dilatation (RV:LV ration > 0.9) on US or CT
        • BNP > 90 pg/L
        • Nt-pro-BNP > 500 pg/mL
        • EKG changes: New RBBB, anteroseptal ST elevation or depression, or anteroseptal TWI
      • Myocardial Necrosis
        • Troponin I > 0.4 ng/mL
        • Troponin T > 0.1 ng/mL
    • Submassive PE and mortality
      • Normotensive PE mortality rate: ~ 0.9%
      • Submassive PE with heparin alone: ~ 3%
        • Take home: Most of these people will not die, and even a decent reduction in mortality by percentage will still be a minimal number of people).  So, we need to look at secondary outcomes
    • Submassive PE: Long term effects - bad lungs, can’t breathe
      • Persistently elevated right ventricular systolic pressure (RVSP)
      • Chronic thromboembolic pulmonary hypertension
    • Treatment
      • Anticoagulation
        • SQ LMWH or IV UFH to objectively confirmed PE w/o contraindication to anticoagulation (Class 1, Level A)
        • Therapeutic anticoagulation during diagnostics with intermediate or high clinical probability of PE and no contraindication to anticoagulation (Class 1 Level C). 
      • Lytics:
        • Massive PE, acceptable bleeding risk: DO IT (Class IIa, Level B)
        • Consider for patients with submassive PE and new hemodynamic change, worsening respiratory status, severe RV dysfunction or myocardial necrosis and acceptable bleeding risk (Class IIb, Level C)
          • Data suggests that treatment with lytics in patients with submassive PE does reduce CTEPH and persistently elevated RVSP in the long term (See Table 7 in the text for the summaries)
          • Two ongoing trials to look at this (both using tenecteplase)
            • Europe: Pulmonary EmbolIsm THrOmbolysis (PEITHO)
            • USA: Tenecteplase Or Placebo: Cardiopulmonary Outcomes At Three Months (TOPCOAT)
      • Low-risk PE and submassive PE with out the above factors should not get lytics (Class III, Level B)
      • Not recommended for undifferentiated cardiac arrest (Class III, Level B)

Recommended algorithm for treatment of Submassive PE:

em res Submassive PE.png

References

Jaff, M et al.  Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension: A Scientific Statement from the American Heart Association.  Circulation, 2011; 123:1788-1830.  

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