Management of Pulmonary Embolism: An Update
Stavros V. Konstantinides, Stefano Barco, Mareike Lankeit, Guy Meyer
Recently published in the Journal of the American College of Cardiology, a team of medical researchers conducted a comprehensive review of management strategies for patients diagnosed with acute pulmonary embolism (PE). Furthermore, the review assessed areas in which further investigation is required.
First, an analysis of the use of an age-adjusted D-dimer test in those classified as having a low-intermediate risk for developing PE may significantly reduce the percentage of diagnostic imaging in lower risk PE patients. Because a positive D-dimer test lacks specificity, cases of low risk patients with positive D-dimer results were undergoing diagnostic imaging at high rates, leading to a potential overuse of CT imaging, which may be considered mismanagement of both time and resources. The use of the age-adjustment in testing allowed for a significant reduction in the amount of CT imaging for (most often elderly) patients with low to intermediate PE risk, thus streamlining the diagnosis process for PE. The study also looked at instances and rates of PE misdiagnosis, and found that “pitfalls and errors resulting in misdiagnosis of PE may be frequent in clinical practice.” Findings suggest this may be due to: discordance between specialists and radiologists, cases in which a purported PE was located in a segmental artery, and breathing motion artifact.
The team then moves to assess the process of risk stratification for PE. More than 95% of patients with a possible PE present as hemodynamically stable, and therefore are not considered high risk. However, within this expansive group, it can be difficult to determine who should be hospitalized and closely monitored, and who can be discharged for outpatient treatment. Questions about the process of determining risk stratification for patients with PE has led to further discussion about the need for a better defined intermediate risk classification. Currently, the European Society of Cardiology (ESC) is working to create a more clear stratification scheme for patients classified as having an intermediate risk specifically by reviewing both imaging and laboratory biomarker processes.
This article also addresses the use of oral agents as safe and effective alternatives to typical anticoagulation methods that have been approved both in the US and European Union. The authors suggest that the use of these oral anticoagulants may be less burdensome to patients and may also be a more cost-effective method of treatment. Of course, those responsible will continue to investigate this new course of treatment for PE patients. Furthermore, in a promising, albeit limiting, study of fibrinolysis as a course of treatment for PE, results showed an overall reduced rate of mortality.
Overall, in both the US and European Union, outcomes for patients with PE are improving in both fatality rates and length of hospital stays. These findings suggest enhanced diagnostic methods and treatment and may be linked to clinical findings on D-dimer testing, greater accuracy in CT imaging, the use of multidisciplinary Pulmonary Embolism Response Teams, and ongoing research. Finally, in it’s thorough discussion of current PE diagnosis and treatment issues, this article addressed major areas for continued investigation, including the use of magnetic resonance imaging, the significance of subsegmental PE, VTE in pregnancy, and PE management in cancer patients.
Journal of the American College of Cardiology. March 2016. doi:10.1016/j.jacc.2015.11.061