Pulmonary Embolism
Acute pulmonary embolism (PE) poses a significant burden on health and survival. Its severity ranges from asymptomatic, incidentally discovered subsegmental thrombi to massive, pressor-dependent PE complicated by cardiogenic shock and multisystem organ failure. Rapid and accurate risk stratification is therefore of paramount importance to ensure the highest quality of care. This article critically reviews currently available and emerging tools for risk-stratifying acute PE, and particularly for distinguishing between elevated (intermediate) and low risk among normotensive patients. We focus on the potential value of risk assessment strategies for optimizing severity-adjusted management. Apart from reviewing the current evidence on advanced early therapy of acute PE (thrombolysis, surgery, catheter interventions, vena cava filters), we discuss recent advances in oral anticoagulation with vitamin K antagonists, and with new direct inhibitors of factor Xa and thrombin, which may contribute to profound changes in the treatment and secondary prophylaxis of venous thrombo-embolism in the near future.
Pulmonary embolism spans a broad spectrum of illness, ranging from asymptomatic, incidentally discovered subsegmental thrombus detected on chest CT scan to pressor-dependent PE complicated by cardiogenic shock and multisystem organ failure. Between these two extremes are patients with symptomatic low-risk or intermediate-risk disease.
As clinicians specializing in cardiovascular medicine, we are likely to be consulted on patients at the sicker end of the risk continuum. Our toolbox of options is rapidly expanding. For the patient without haemodynamic compromise, we can offer conventional unfractionated heparin, low-molecular-weight heparin (LMWH), or fondaparinux as a 'bridge' to vitamin K antagonists. More recently, oral monotherapy anticoagulation (without any injectable or intravenous anticoagulant) was reported to be safe and effective. On the other hand, some normotensive and most unstable patients will require specific advanced therapy, in addition to parenteral anticoagulation. Options for advanced therapy include placement of an inferior vena cava filter, systemic thrombolysis, open surgical embolectomy, or pharmacomechanical therapy.
This article critically reviews currently available and emerging tools for risk-stratifying acute PE as well as severity-adjusted management strategies. We also discuss the recent advances in oral anticoagulation with vitamin K antagonists, and with new direct inhibitors of factor Xa and thrombin which are being introduced into the market and may contribute to profound changes in the treatment strategy for acute venous thrombo-embolism in the near future.
Abstract and Introduction
Abstract
Acute pulmonary embolism (PE) poses a significant burden on health and survival. Its severity ranges from asymptomatic, incidentally discovered subsegmental thrombi to massive, pressor-dependent PE complicated by cardiogenic shock and multisystem organ failure. Rapid and accurate risk stratification is therefore of paramount importance to ensure the highest quality of care. This article critically reviews currently available and emerging tools for risk-stratifying acute PE, and particularly for distinguishing between elevated (intermediate) and low risk among normotensive patients. We focus on the potential value of risk assessment strategies for optimizing severity-adjusted management. Apart from reviewing the current evidence on advanced early therapy of acute PE (thrombolysis, surgery, catheter interventions, vena cava filters), we discuss recent advances in oral anticoagulation with vitamin K antagonists, and with new direct inhibitors of factor Xa and thrombin, which may contribute to profound changes in the treatment and secondary prophylaxis of venous thrombo-embolism in the near future.
Introduction
Pulmonary embolism spans a broad spectrum of illness, ranging from asymptomatic, incidentally discovered subsegmental thrombus detected on chest CT scan to pressor-dependent PE complicated by cardiogenic shock and multisystem organ failure. Between these two extremes are patients with symptomatic low-risk or intermediate-risk disease.
As clinicians specializing in cardiovascular medicine, we are likely to be consulted on patients at the sicker end of the risk continuum. Our toolbox of options is rapidly expanding. For the patient without haemodynamic compromise, we can offer conventional unfractionated heparin, low-molecular-weight heparin (LMWH), or fondaparinux as a 'bridge' to vitamin K antagonists. More recently, oral monotherapy anticoagulation (without any injectable or intravenous anticoagulant) was reported to be safe and effective. On the other hand, some normotensive and most unstable patients will require specific advanced therapy, in addition to parenteral anticoagulation. Options for advanced therapy include placement of an inferior vena cava filter, systemic thrombolysis, open surgical embolectomy, or pharmacomechanical therapy.
This article critically reviews currently available and emerging tools for risk-stratifying acute PE as well as severity-adjusted management strategies. We also discuss the recent advances in oral anticoagulation with vitamin K antagonists, and with new direct inhibitors of factor Xa and thrombin which are being introduced into the market and may contribute to profound changes in the treatment strategy for acute venous thrombo-embolism in the near future.
Source...