Pulmonary embolism response teams: Purpose, evidence for efficacy, and future research directions

Radiology-Led Pulmonary Embolism Response Team (PERT) Activation: Initial Experience

This study implemented and evaluated a Pulmonary Embolism Response Team (PERT) activated at the time of radiologic diagnosis of pulmonary embolism (PE). From August 2021 to March 2023, 524 PE diagnoses were made. A clinical algorithm was created using a multidisciplinary team approach. Upon PE diagnosis, diagnostic radiologists paged the PERT, who then clinically stratified PE severity. Clinical stratification of diagnosed PEs were 34% low risk, 35% intermediate-low risk, 27% intermediate-high risk, and 3% high risk. In summary, this study discusses the formation and our initial experience of a PERT activated at the time of radiology imaging diagnosis, including implementation, positive and negative attributes, and future directions.This novel algorithm showed implementing a radiology-activated PERT provides benefits including streamlined clinical stratification, improved PE detection, risk stratification, and care coordination. Further study of clinical outcomes and comparative analysis with artificial intelligence (AI) platforms is warranted.

Basics of diagnosis and treatment of venous thromboembolism

Venous thromboembolism (VTE), comprising deep vein thrombosis and pulmonary embolism (PE), is common and associated with significant morbidity and mortality. The symptoms and signs of VTE are nonspecific. Well-established integrated diagnostic strategies combining clinical probability scores and D-dimer are used to identify patients with a low probability of VTE, where the diagnosis can be safely excluded without imaging. In patients with confirmed VTE, anticoagulation is the mainstay of treatment. However, patients with high-risk features at presentation may benefit from advanced reperfusion therapies such as thrombolysis and/or interventional approaches to reduce early mortality and/or long-term morbidity. The advent of direct oral anticoagulants has greatly simplified the treatment of VTE for most patients, with a persisting role for low molecular weight heparin and vitamin K antagonists in select patient groups. Following an initial 3 to 6 months of anticoagulation, those with major transient provoking factors can safely discontinue anticoagulation. Balancing the risk of recurrent VTE and bleeding risk is central to decisions regarding long-term anticoagulation, and patients should be included in shared decision-making. Assessment and recognition of common long-term complications such as postthrombotic syndrome and post-PE syndrome are also essential, given they are associated with significant adverse impact on long-term quality of life, with a significant risk of mortality associated with the less frequent complication of chronic thromboembolic pulmonary hypertension. This review provides a basic overview and framework for the diagnostic approach to deep vein thrombosis and PE, risk stratification of confirmed diagnoses, and management.

Rationale and design of the PE-TRACT trial: A multicenter randomized trial to evaluate catheter-directed therapy for the treatment of intermediate-risk pulmonary embolism

BACKGROUND

The optimal management of patients with intermediate-risk pulmonary embolism (PE), who have right heart dysfunction (determined by a combination of imaging and cardiac biomarkers) but a normal blood pressure, is uncertain. These patients suffer from reduced functional capacity and a lower quality of life over the long-term, despite use of anticoagulant therapy. Catheter-directed therapy (CDT) is a promising treatment for acute PE that rapidly removes thrombus and potentially improves cardiac dysfunction. However, CDT has risk and is costly, and it is not known whether it improves long-term cardiorespiratory fitness and/or quality of life compared with anticoagulation alone.

METHODS

We are therefore conducting an open-label, assessor-blinded, multicenter randomized trial, the Pulmonary Embolism: Thrombus Removal with Catheter-Directed Therapy (PE-TRACT) Study, to compare CDT plus anticoagulation (CDT group) with anticoagulation alone (No-CDT group) in 500 patients with intermediate-risk PE. The primary study hypothesis is that CDT will increase the peak oxygen uptake (peak VO2) with cardiopulmonary exercise testing at 3 months and reduce New York Heart Association (NYHA) Class at 12 months compared with No-CDT. These 2 primary efficacy outcomes will be analyzed sequentially using a "gatekeeping" procedure; for NYHA class to be compared, peak oxygen consumption must first be shown to be significantly increased by CDT. Safety and cost-effectiveness will also be assessed.

CONCLUSION

When completed, PE-TRACT will provide important evidence regarding the benefits and risks of CDT to treat intermediate-risk PE compared with anticoagulation alone.

TRIAL REGISTRATION

clinicaltrials.gov: NCT05591118.

Bringing PERT to Pediatrics: Initial Experience and Outcomes of a Pediatric Multidisciplinary Pulmonary Embolism Response Team (PERT)

BACKGROUND

Multidisciplinary pulmonary embolism response teams (PERTs) streamline care of adults with life-threatening pulmonary embolism (PE). Given rarity of pediatric PE, developing a clinical, educational, and research PERT paradigm is a novel and underused concept in pediatrics.

RESEARCH QUESTION

Is a PERT feasible in pediatrics, and does it improve PE care?

STUDY DESIGN AND METHODS

A strategy-to-execution proposal to launch a pediatric PERT was developed for institutional buy-in. Key stakeholders collectively implemented the PERT. Data were collected for the 2-year pre-PERT and post-PERT eras, and outcomes were compared.

RESULTS

PERT implementation took 12 months. Our PERT, led by hematology, is composed of pediatric experts in emergency medicine, critical care, interventional cardiology, anesthesiology, and interventional radiology. Data on 30 patients pre-PERT and 31 patients post-PERT were analyzed. Pre-PERT, 10% (3 of 30), 13% (4 of 30), 20% (6 of 30), and 57% (17 of 30), and post-PERT, 3% (1 of 31), 10% (3 of 31), 16% (5 of 31), and 71% (22 of 31) were categorized as high-risk, intermediate-low-risk, intermediate-high-risk, and low-risk PE, respectively. Post-PERT, there were 13 unique PERT activations. PERT was activated on all eligible patients with PE and, additionally, on four low-risk PEs. Time to echocardiogram was shorter post-PERT (4.7 vs 2 hours; P = .0147). Anticoagulation was ordered (90 vs 54 min; P = .003) and given sooner (154 vs 113 min; P = .049) post-PERT. There were no differences in time to reperfusion therapies (12 hours pre-PERT vs 8.7 hours post-PERT, P = .10). Five of six (83.3%) eligible (intermediate-high and high-risk) patients received reperfusion therapies in the post-PERT era compared to three of eight (37.5%) eligible patients in the pre-PERT era (P = .0001). There were no differences in major bleeding, mortality, or length of stay in either era.

INTERPRETATION

The pediatric PERT paradigm was successfully created and adopted locally. Our PERT enhanced access to experts, facilitated timely advanced therapies, and held value for low-risk PE. The University of Texas Southwestern Medical Center and Children's Medical Center pediatric PERT may serve as a best practice model for streamlining care for pediatric PE.

The Etiology and Management of Critical Acute Right Heart Failure

Right ventricular failure contributes to the morbidity and mortality of acute myocardial function, massive pulmonary embolism, and chronic pulmonary hypertension. Understanding how the normal physiology of the right ventricle (RV) is disrupted is integral to managing patients who present with RV decompensation. Therapeutic advances in mechanical circulatory support, pharmacotherapies to reduce afterload, mechanical and chemical lytic therapies for acute pulmonary embolism have improved outcomes of patients by offloading the RV. In this report we provide an overview of the physiology of the RV, medical management (volume optimization, hemodynamic targets, rhythm management), along with critical care-specific topics (induction with mechanical ventilation, sedation strategies, and mechanical circulatory support) and provide a framework for managing patients who present with leveraging principles of preload, contractility, and afterload. Last, because of the complexity of right ventricular failure management, and the complexity of presentation, we also discuss the role of team-based approach (cardiogenic shock and pulmonary embolism response teams), and highlight its benefits at improving outcomes.

The influence of patient sex on pulmonary embolism evaluation, treatment modality, and outcomes

BACKGROUND

Pulmonary embolism (PE) is the third-leading cause of cardiovascular mortality, accounting for 100,000 deaths per year in the United States. Although sex-based disparities have previously been described in this population, it is unclear if these differences have persisted with the expansion of PE evaluation and treatment approaches. The purpose of this study is to investigate sex-based differences in the evaluation, management, and outcomes of patients with acute PE.

METHODS

We performed a retrospective analysis of patients enrolled in the national Pulmonary Embolism Response Team (PERT) Consortium database between October 2015 and October 2022. We evaluated patient demographics, clinical characteristics, diagnostic imaging performed, treatment at several phases of care (pre-PERT, PERT recommendations, and post-PERT), and clinical outcomes.

RESULTS

A total of 5722 patients with acute PE (2838 [49.6%] women) from 35 centers were included. There were no differences in PE risk category between male and female patients. Women were less likely to undergo echocardiography (76.9% vs 73.8%) and more likely to receive no anticoagulation prior to PERT evaluation (35.5% vs 32.9%). PERT teams were more likely to recommend catheter-based interventions for men (26.6% vs 23.1%), and men were more likely to undergo these procedures (21.9% vs 19.3%). In a multivariable analysis, female sex was a predictor of in-hospital mortality (OR 1.53, 95% CI 1.06 to 2.21).

CONCLUSIONS

In this analysis, we identified sex-based differences in the evaluation and management of patients presenting with acute PE. Subsequently, women presenting with acute PE were at higher risk of in-hospital mortality.

Mechanical Thrombectomy for Acute Pulmonary Embolism in Non-Operating Room Anesthesia (NORA) Locations: Best Safety Practices and Local Insights

Mortality rates from pulmonary embolism (PE) remain significant, highlighting the need for alternative treatment strategies beyond traditional anticoagulation. Percutaneous interventions, including mechanical thrombectomy and catheter-directed thrombolysis, are emerging as promising options. Given the complex pathophysiology and unique risk profiles of these patients, meticulous multidisciplinary planning is essential. Anesthesiologists play a central role in coordinating care and managing perioperative risks to improve outcomes. This article provides insights into best safety practices and shares experiences from a leading quaternary center. It offers guidance for anesthesia providers to proactively engage in comprehensive risk stratification, participate in multidisciplinary discussions, and support robust contingency planning for managing PE patients undergoing percutaneous interventions in non-operating room anesthesia settings.

Time trends of catheter-directed treatment in acute pulmonary embolism in Germany

Background

Catheter-directed treatment (CDT) is an innovative treatment for patients with elevated risk pulmonary embolism (PE) to resolve embolus and restore pulmonary perfusion.

Objectives

We aimed to analyse the use and the benefit of CDT in PE patients in Germany.

Methods

The German nationwide inpatient sample was used to include all hospitalizations of patients with PE from 2005 to 2020 in Germany. PE patients were stratified for CDT usage. Temporal trends and the impact of CDT on case fatality and other outcomes were investigated.

Results

Overall, 1,373,084 hospitalizations of patients with PE (55.9% aged ≥70 years; 53.0% females) were included in this study from 2005 to 2020, and among these, 427,238 (31.1%) patients were categorized as having elevated-risk PE and 3330 (0.2%) were treated with CDT with annual increase from 0.17% (2005) to 0.51% (2020). PE patients of younger age, male sex, with previous surgery, and elevated-risk PE were more often treated with CDT. In patients with elevated risk-PE, CDT attributed to a lower observed rate of major adverse cardiac and cerebrovascular events (major adverse cardiac and cerebrovascular events [MACCE]; 28.2% vs 34.2%; P < .001) and in-hospital case fatality (24.9% vs 31.0%; P < .001). CDT was associated with reduced MACCE (OR, 0.91; 95% CI, 0.83-0.99) and with a trend toward lower case fatality (OR, 0.92; 95% CI, 0.84-1.01). The benefit of CDT regarding case fatality was age-dependent.

Conclusion

Although the annual rate of CDT increased in Germany between 2005 and 2020, only 0.2% of the PE patients were treated with CDT. Selection criteria for CDT treatment were younger age, male sex, previous surgery, and elevated risk-PE. CDT treatment was associated with reduced MACCE and case-fatality rate in PE patients with elevated-risk PE.

Pulmonary Embolism Response Teams-Evidence of Benefits? A Systematic Review and Meta-Analysis

Background: Venous thromboembolisms constitute a major cause of morbidity and mortality with 60,000 to 100,000 deaths attributed to pulmonary embolism in the US annually. Both clinical presentations and treatment strategies can vary greatly, and the selection of an appropriate therapeutic strategy is often provider specific. A pulmonary embolism response team (PERT) offers a multidisciplinary approach to clinical decision making and the management of high-risk pulmonary emboli. There is insufficient data on the effect of PERT programs on clinical outcomes. Methods: We searched PubMed, Scopus, Web of Science, and Cochrane to identify PERT studies through March 2024. The primary outcome was all-cause mortality, and the secondary outcomes included the rates of surgical thrombectomy, catheter directed thrombolysis, hospital length of stay (HLOS), and ICU length of stay (ICULOS). We used the Newcastle-Ottawa Scale tool to assess studies' quality. We used random-effects models to compare outcomes between the pooled populations and moderator analysis to identify sources of heterogeneity and perform subgroup analysis. Results: We included 13 observational studies, which comprised a total of 12,586 patients, 7512 (60%) patients were from the pre-PERT period and 5065 (40%) patients were from the PERT period. Twelve studies reported the rate of all-cause mortality for their patient population. Patients in the PERT period were associated with similar odds of all-cause mortality as patients in the pre-PERT period (OR: 1.52; 95% CI: 0.80-2.89; p = 0.20). In the random-effects meta-analysis, there was no significant difference in ICULOS between PERT and pre-PERT patients (difference in means: 0.08; 95% CI: -0.32 to 0.49; p = 0.68). There was no statistically significant difference in HLOS between the two groups (difference in means: -0.82; 95% CI: -2.86 to 1.23; p = 0.43). Conclusions: This meta-analysis demonstrates no significant difference in all studied measures in the pre- and post-PERT time periods, which notably included patient mortality and length of stay. Further study into the details of the PERT system at institutions reporting mortality benefits may reveal practice differences that explain the outcome discrepancy and could help optimize PERT implementation at other institutions.

Clinical Profile and Outcomes of Pulmonary Embolism in Central Iran: A Retrospective Cohort Study

BACKGROUND

Pulmonary embolism (PE) is a significant public health concern. This retrospective cohort study examines the clinical profiles and outcomes of patients diagnosed with PE at a medical center in central Iran, aiming to identify mortality predictors during hospitalization and follow-up.

METHODS

Data from 109 patients diagnosed with PE were analyzed, with a median follow-up of 23 months. The collected information included demographic and clinical characteristics, laboratory findings, treatment protocols, and outcomes. Logistic regression and Kaplan-Meier survival analysis were used to identify independent mortality predictors and assess survival impact.

RESULTS

The mean age was 59.2 years (±19.7), with 51.4% male. Common symptoms included dyspnea (86%) and chest pain (53%), with non-massive PE being the most prevalent (63%). Independent mortality predictors identified were age (odds ratio [OR] 1.065 per year, P<0.001), female sex (OR 4.421, P=0.009), and PE severity (OR 0.262, P=0.023). Kaplan-Meier analysis showed reduced survival probabilities in females (P=0.009), those with provoked PE (P=0.002), patients over 65 (P=0.016), and individuals with comorbidities (P=0.018). In-hospital mortality was 10.1%, linked to provoked massive PE, absence of thrombolytic therapy, and reduced left ventricular ejection fraction (LVEF).

CONCLUSION

In this cohort, age, sex, and PE severity were significant mortality predictors, while provoked PE, advanced age, and comorbidities were associated with lower mid-term survival probabilities.

International Clinical Practice Guideline Recommendations for Acute Pulmonary Embolism: Harmony, Dissonance, and Silence

Despite abundant clinical innovation and burgeoning scientific investigation, pulmonary embolism (PE) has continued to pose a diagnostic and management challenge worldwide. Aging populations, patients living with a mounting number of chronic medical conditions, particularly cancer, and increasingly prevalent health care disparities herald a growing burden of PE. In the meantime, navigating expanding strategies for immediate and long-term anticoagulation, as well as advanced therapies, including catheter-based interventions for patients with more severe PE, has become progressively daunting. Accordingly, clinicians frequently turn to evidence-based clinical practice guidelines for diagnostic and management recommendations. However, numerous international guidelines, heterogeneity in recommendations, as well as areas of uncertainty or omission may leave the readers and clinicians without a clear management pathway. In this review of international PE guidelines, we highlight key areas of consistency, difference, and lack of recommendations (silence) with an emphasis on critical clinical and research needs.

Severe Traumatic Brain Injury and Pulmonary Embolism: Risks, Prevention, Diagnosis and Management

Severe traumatic brain injury (sTBI) is a silent epidemic, causing approximately 300,000 intensive care unit (ICU) admissions annually, with a 30% mortality rate. Despite worldwide efforts to optimize the management of patients and improve outcomes, the level of evidence for the treatment of these patients remains low. The concomitant occurrence of thromboembolic events, particularly pulmonary embolism (PE), remains a challenge for intensivists due to the risks of anticoagulation to the injured brain. We performed a literature review on sTBI and concomitant PE to identify and report the most recent advances on this topic. We searched PubMed and Scopus for papers published in the last five years that included the terms "pulmonary embolism" and "traumatic brain injury" in their title or abstract. Exclusion criteria were papers referring to children, non-sTBI populations, and post-acute care. Our search revealed 75 papers, of which 38 are included in this review. The main topics covered include the prevalence of and risk factors for pulmonary embolism, the challenges of timely diagnosis in the ICU, the timing of pharmacological prophylaxis, and the treatment of diagnosed PE.

A Brief Historical Perspective on Pulmonary Embolism

Pulmonary embolism is a major cause of mortality worldwide. In this historical perspective, we aim to provide an overview of the rich medical history surrounding pulmonary embolism. We highlight Virchow's first steps toward understanding the pathophysiology in the 1800s. We see how those insights inspired early attempts at intervention such as surgical pulmonary embolectomy and caval ligation. Those early interventions were refined and ultimately led to the development of inferior vena cava filters, the earliest clinical applications of anticoagulation, and even apparently disparate medical advances such as the successful development of cardiopulmonary bypass. We also see how the diagnosis of pulmonary embolism has evolved from rudimentary monitoring of vitals and symptoms to the development of evermore sophisticated tests such as contrast tomography angiography and echocardiography. Finally, we discuss current approaches to diagnosis, classification, and myriad treatments including anticoagulation, thrombolysis, catheter-directed interventions, surgical embolectomy, and extracorporeal membrane oxygenation guided by Pulmonary Embolism Response Teams.

Integration of Extracorporeal Membrane Oxygenation into the Management of High-Risk Pulmonary Embolism: An Overview of Current Evidence

High-risk pulmonary embolism (PE) refers to a large embolic burden causing right ventricular failure and hemodynamic instability. It accounts for approximately 5% of all cases of PE but contributes significantly to overall PE mortality. Systemic thrombolysis is the first-line revascularization therapy in high-risk PE. Surgical embolectomy or catheter-directed therapy is recommended in patients with an absolute contraindication to systemic thrombolysis. Extracorporeal membrane oxygenation (ECMO) provides respiratory and hemodynamic support for the most critically ill PE patients with refractory cardiogenic shock or cardiac arrest. The complex management of these individuals requires urgent yet coordinated multidisciplinary care. In light of existing evidence regarding the utility of ECMO in the management of high-risk PE patients, a number of possible indications for ECMO utilization have been suggested in the literature. Specifically, in patients with refractory cardiac arrest, resuscitated cardiac arrest, or refractory shock, including in cases of failed thrombolysis, venoarterial ECMO (VA-ECMO) should be considered, either as a bridge to percutaneous or surgical embolectomy or as a bridge to recovery after surgical embolectomy. We review here the current evidence on the use of ECMO as part of the management strategy for the highest-risk presentations of PE and summarize the latest data in this indication.

Considerations for instituting pediatric pulmonary embolism response teams: A tool kit

The incidence of pediatric pulmonary embolism (PE) has increased by 200 % in the last decade, but at a single center, it is still infrequent. Given the unique epidemiologic features of pediatric PE, diagnosis is often delayed, and the management is empiric, based on individual physician experience or preference. Thus, there is a strong need for center-specific uniform management of pediatric PE patients. In adults, the development of pulmonary embolism response teams (PERTs) or PE critical care pathways has shortened the time to diagnosis and the initiation of definitive management. Evidence to support an improvement in PE outcomes after the development of PERTs does not exist in children. Nonetheless, we have summarized the practical practice guidelines that physicians and institutions can adopt to establish their institutional PERTs or critical pathways. We also provide strategies for resource-challenged institutions for partnering with centers with expertise in the management of pediatric PE.

Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities

BACKGROUND

Deaths from high-risk pulmonary embolism (PE) appear to have increased in the US over the last decade. Modifiable risks contributing to this worrisome trend present opportunities for physicians, researchers, and healthcare policymakers to improve care.

METHODS

We sought to contextualize contemporary, high-risk PE epidemiology and examine clinical trials, quality improvement opportunities, and healthcare policy initiatives directed at reducing mortality.

RESULTS

We observed significant and modifiable excess mortality due to high-risk PE. We identified several opportunities to improve care including: (1) rapid translation of forthcoming data on reperfusion strategies into clinical practice; (2) improved risk stratification tools; (3) quality improvement initiatives to address presumptive anticoagulation practice gaps; and (3) adoption of health policy initiatives to establish pulmonary embolism response teams and address the social determinants of health.

CONCLUSION

Addressing knowledge and practice gaps in intermediate and high-risk PE management must be prioritized and informed by forthcoming high-quality data. Implementation efforts are needed to improve acute PE management and resolve treatment disparities.

Ultrasound-Assisted Catheter-Directed Thrombolysis for the Management of Pulmonary Embolism: A Single Center Experience in a Community Hospital

Current guidelines recommend anticoagulation alone for low-risk pulmonary embolism (PE) with the addition of systemic thrombolysis for high-risk PE. However, treatment recommendations for intermediate-risk PE are not well-defined. Due to bleeding risks associated with systemic thrombolysis, ultrasound-assisted catheter-directed thrombolysis (USAT) has evolved as a promising treatment modality. USAT is thought to decrease the rate of major bleeding by using localized delivery with lower thrombolytic dosages. Currently, there is little guidance on the implementation of USAT in the real-world clinical setting. This study was designed to evaluate our experience with USAT at this single community hospital with a newly initiated Pulmonary Embolism Response Team (PERT). All patients identified by the PERT with an acute PE diagnosed by a computed tomography (CT) scan from January 2021 to January 2023 were included. During the study period, there were 89 PERT activations with 40 patients (1 high-risk and 37 intermediate-risk PE) receiving USAT with alteplase administered at a fixed rate of 1 mg/h per catheter for 6 h. The primary efficacy outcome was the change in Pulmonary Embolism Severity Index (PESI) score within 48 h after USAT. The primary safety outcome was major bleeding within 72 h. The mean age was 57.4 ± 17.4 years and 50% (n = 20) were male, 17.5% (n = 7) had active malignancy, and 20% (n = 8) had a history of prior deep vein thrombosis (DVT) or PE. The mean PESI score decreased from baseline to 48 h post-USAT (84.7 vs 74.9; p = 0.025) and there were no major bleeding events. The overall hospital length of stay was 7.5 ± 9.8 days and ICU length of stay was 2.2 ± 2.8 days. This study outlined our experience at this single community hospital which resulted in an improvement in PESI scores and no major bleeding events observed.

Implementing a Pediatric Pulmonary Embolism Response Team Model: An Institutional Experience

Pulmonary embolism is increasing in prevalence among pediatric patients; although still rare, it can create a significant risk for morbidity and death within the pediatric patient population. Pulmonary embolism presents in various ways depending on the patient, the size of the embolism, and the comorbidities. Treatment decisions are often driven by the severity of the presentation and hemodynamic effects; severe presentations require more invasive and aggressive treatment. We describe the development and implementation of a pediatric pulmonary embolism response team designed to facilitate rapid, multidisciplinary, data-driven treatment decisions and management.

Pulmonary embolism: a practical approach to update risk stratification and treatment decisions based on the guidelines

INTRODUCTION

Pulmonary embolism (PE) is a prevalent condition with a substantial morbi-mortality worldwide. Proper risk stratification of PE is essential for identifying the most suitable therapeutic strategy and the optimal care setting for the patient. This process entails evaluating various factors, including symptoms, comorbidities, and right heart dysfunction.

AREAS COVERED

This review assesses the tools and methods utilized to identify and stratify individuals based on the probability of developing deterioration or death related to PE. Current guidelines divide PE into three groups: high-risk (previously termed massive) PE, intermediate-risk (sub-massive) PE, and low-risk PE. Various risk scores, such as the simplified pulmonary embolism severity index (sPESI), Bova score, and the FAST score (incorporating Heart-Fatty Acid binding protein [H-ABP], Syncope, Tachycardia), aid in identifying patients at higher risk. Additionally, the Hestia score is instrumental in pinpointing low-risk patients.

EXPERT OPINION

Presently, there is a dearth of high-quality frameworks for the optimal management and treatment of PE patients at risk of hemodynamic collapse. A consortium of experts is in the process of formulating a new conceptual model for risk stratification, taking into account a comprehensive array of variables and outcomes to facilitate more individualized management of acute PE.

Shock Teams: A Contemporary Review

PURPOSE OF REVIEW

Cardiogenic shock (CS) is a time-sensitive and often fatal condition. To address this issue, many centers have developed multidisciplinary shock teams with a common goal of expediting the recognition and treatment of CS. In this review, we examine the mission, structure, implementation, and outcomes reported by these early shock teams.

RECENT FINDINGS

To date, there have been four observational shock team analyses, each providing unique insight into the utility of the shock team. The limited available data supports that shock teams are associated with improved CS mortality. However, there is considerable operational heterogeneity among shock teams, and randomized data assessing their value and best practices in both local and regional care models are needed.

Sex, Racial, and Geographic Disparities in Pulmonary Embolism-related Mortality Nationwide

Rationale: Acute pulmonary embolism is a leading cause of cardiovascular death. There are limited data on the national mortality trends from pulmonary embolism. Understanding these trends is crucial for addressing the mortality and associated disparities associated with pulmonary embolism. Objectives: To analyze the national mortality trends related to acute pulmonary embolism and determine the overall age-adjusted mortality rate (AAMR) per 100,000 population for the study period and assess changes in AAMR among different sexes, races, and geographic locations. Methods: We conducted a retrospective cohort analysis using mortality data of individuals aged ⩾15 years with pulmonary embolism listed as the underlying cause of death in the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from January 2006 to December 2019. These data are produced by the National Center for Health Statistics. Results: A total of 109,992 pulmonary embolism-related deaths were noted in this dataset nationwide between 2006 and 2019. Of these, women constituted 60,113 (54.7%). The AAMR per 100,000 was not significantly changed, from 2.84 in 2006 to 2.81 in 2019 (average annual percentage change [AAPC], 0.2; 95% confidence interval [CI], -0.1 to 0.5; P = 0.15). AAMR increased for men throughout the study period compared with women (AAPC, 0.7 for men; 95% CI, 0.3 to 1.2; P = 0.004 vs. AAPC, -0.4 for women; 95% CI, -1.1 to 0.3; P = 0.23, respectively). Similarly, AAMR for pulmonary embolism increased for Black compared with White individuals, from 5.18 to 5.26 (AAPC, 0.4; 95% CI, 0.0 to 0.7; P = 0.05) and 2.82 to 2.86 (AAPC, 0.0; 95% CI, -0.6 to 0.6; P = 0.99), respectively. Similarly, AAMR for pulmonary embolism was higher in rural areas than in micropolitan and large metropolitan areas during the study period (4.07 [95% CI, 4.02 to 4.12] vs. 3.24 [95% CI, 3.21 to 3.27] vs. 2.32 [95% CI, 2.30-2.34], respectively). Conclusions: Pulmonary embolism mortality remains high and unchanged over the past decade, and enduring sex, racial and socioeconomic disparities persist in pulmonary embolism. Targeted efforts to decrease pulmonary embolism mortality and address such disparities are needed.

Contemporary trends in mortality related to high-risk pulmonary embolism in US from 1999 to 2019

BACKGROUND

Population-based data on high-risk pulmonary embolism (PE) mortality trends in the United States (US) are scant.

OBJECTIVES

To assess current trends in US mortality related to high-risk PE over the past 21 years and determine differences by sex, race, ethnicity, age and census region.

METHODS

Data were extracted from the Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) to determine trends in age-adjusted mortality rates (AAMR) per 100,000 people, due to high-risk PE. To calculate nationwide annual trends, we assessed the average (AAPC) and annual percent change (APC) with relative 95 % confidence intervals (CIs) using Joinpoint regression.

RESULTS

Between 1999 and 2019, high-risk PE was listed as the underlying cause of death in 209,642 patients, corresponding to an AAMR of 3.01 per 100,000 people (95 % CI: 2.99 to 3.02). AAMR from high-risk PE remained stable from 1999 to 2007 [APC: -0.2 %, (95 % CI: -2.0 to 0.5, p = 0.22)] and then significantly increased [APC: 3.1 % (95 % CI: 2.6 to 3.6), p < 0.0001], especially in males [AAPC: 1.9 % (95 % CI: 1.4 to 2.4), p < 0.001 vs AAPC: 1.5 % (95 % CI: 1.1 to 2.2), p < 0.001]. AAMR increase was more pronounced in those <65 years, Black Americans, and residents of rural areas.

CONCLUSIONS

In an US population analysis, high-risk PE mortality rate increased, with racial, sex-based, and regional variations. Further studies are needed to understand root causes for these trends and to implement appropriate corrective strategies.

Clinical profile and outcome of isolated pulmonary embolism: a systematic review and meta-analysis

Background

Isolated pulmonary embolism (PE) appears to be associated with a specific clinical profile and sequelae compared to deep vein thrombosis (DVT)-associated PE. The objective of this study was to identify clinical characteristics that discriminate both phenotypes, and to characterize their differences in clinical outcome.

Methods

We performed a systematic review and meta-analysis of studies comparing PE phenotypes. A systematic search of the electronic databases PubMed and CENTRAL was conducted, from inception until January 27, 2023. Exclusion criteria were irrelevant content, inability to retrieve the article, language other than English or German, the article comprising a review or case study/series, and inappropriate study design. Data on risk factors, clinical characteristics and clinical endpoints were pooled using random-effects meta-analyses.

Findings

Fifty studies with 435,768 PE patients were included. In low risk of bias studies, 30% [95% CI 19-42%, I ² = 97%] of PE were isolated. The Factor V Leiden [OR: 0.47, 95% CI 0.37-0.58, I ² = 0%] and prothrombin G20210A mutations [OR: 0.55, 95% CI 0.41-0.75, I ² = 0%] were significantly less prevalent among patients with isolated PE. Female sex [OR: 1.30, 95% CI 1.17-1.45, I ² = 79%], recent invasive surgery [OR: 1.31, 95% CI 1.23-1.41, I ² = 65%], a history of myocardial infarction [OR: 2.07, 95% CI 1.85-2.32, I ² = 0%], left-sided heart failure [OR: 1.70, 95% CI 1.37-2.10, I ² = 76%], peripheral artery disease [OR: 1.36, 95% CI 1.31-1.42, I ² = 0%] and diabetes mellitus [OR: 1.23, 95% CI 1.21-1.25, I ² = 0%] were significantly more frequently represented among isolated PE patients. In a synthesis of clinical outcome data, the risk of recurrent VTE in isolated PE was half that of DVT-associated PE [RR: 0.55, 95% CI 0.44-0.69, I ² = 0%], while the risk of arterial thrombosis was nearly 3-fold higher [RR: 2.93, 95% CI 1.43-6.02, I ² = 0%].

Interpretation

Our findings suggest that isolated PE appears to be a specific entity that may signal a long-term risk of arterial thrombosis. Randomised controlled trials are necessary to establish whether alternative treatment regimens are beneficial for this patient subgroup.

Funding

None.

A Rapid Response Team (RRT) System at a Cancer Center: Innovative Approaches to System Organization and Clinical RRT Pathways

The Rapid Response Team (RRT) system at Memorial Sloan Kettering Cancer Center led by critical care medicine (CCM) advanced practice providers (APPs) expanded exponentially between 2009 and 2021. CCM-APPs are trained for care of critically ill patients as well as to oversee rapid response calls. The RRT is composed of a CCM-based RRT-APP, respiratory therapist, RRT-RN, and nursing supervisor. Since program inception, 11 RRT pathways and interventions have been developed and adjusted to improve multidisciplinary patient management. Pathways vary in complexity and require multidisciplinary collaboration. In some circumstances, the RRT patient may require transfer to outside facilities for services not provided at our oncology-based facility. RRT data are tracked across the hospital continuum with on-line reporting through RRT website dashboards. 2021 RRT data on electronic sepsis alerts, behavioral RRT and stroke alerts are presented. The RRT program is monitored through robust quality assurance. The APP-led RRT system's scope of care has been continuously expanded through the creation of RRT pathways to meet the increasingly complex medical needs of our patients.

Blueprint for developing an effective pulmonary embolism response network

INTRODUCTION

Acute pulmonary embolism (PE) is a major cause of morbidity and mortality in Portugal. It is the third most common cause of cardiovascular death after stroke and myocardial infarction. However, the management of acute PE remains poorly standardized, and there is a lack of access to mechanical reperfusion when indicated.

METHODS AND RESULTS

This working group analyzed the current clinical guidelines for the use of percutaneous catheter-directed treatment in this setting and proposed a standardized approach for severe forms of acute PE. This document also proposes a methodology for the coordination of regional resources in order to create an effective PE response network, based on the hub-and-spoke organization design.

CONCLUSION

This model can be applied at the regional level, but it is desirable to extend it to the national level.

Acute Pulmonary Embolism Code and Rapid Response Teams are Necessary: A Review of Global and Mexico's Teams (MGH PERT)

Pulmonary embolism (PE) worldwide is an underdiagnosed disease; at the moment, there are no statistical data to make inferences regarding the thrombotic problem in Mexico. Although, in general, small emboli (subsegmental) are well tolerated in the pulmonary circulation, difficulties frequently occur for medium to large emboli that occlude more than 30% of the pulmonary circulation. In the United States, it is estimated that up to 100,000 PE-related deaths occur each year. A PE code consists of activating a group of specialists in PE for the consensual making of therapeutic decisions; it is beneficial for the clinical evolution of these patients and reduces their mortality; a PE response team (PERT) codes in reference hospitals to manage this disease. This report presents an updated summary of the PERT status globally and in Mexico, the explanation of why a PE code is necessary, and the effects of PERT teams in the detection (chronic thromboembolic pulmonary hypertension, chronic thromboembolic disease, and venous thromboembolism); therapeutic procedures (catheter-directed thrombolysis, systemic thrombolysis or surgical thrombectomy); selection of patients from low to high risk of PE; and future directions for PERT teams.

Pulmonary embolism response teams: Changing the paradigm in the care for acute pulmonary embolism

Pulmonary embolism response teams (PERTs) have emerged as a multidisciplinary, multispecialty team of experts in the care of highly complex symptomatic acute pulmonary embolism (PE), with a centralized unique activation process, providing rapid multimodality assessment and risk stratification, formulating the best individualized diagnostic and therapeutic approach, streamlining the care in challenging clinical case scenarios (e.g., intermediate-high risk and high-risk PE), and facilitating the implementation of the recommended therapeutic strategies on time. PERTs are currently changing how complex acute PE cases are approached. The structure, organization, and function of a given PERT may vary from hospital to hospital, depending on local expertise, specific resources, and infrastructure for a given academic hospital center. Current emerging data demonstrate the value of PERTs in improving time to PE diagnosis; shorter time to initiation of anticoagulation reducing hospital length of stay; increasing use of advanced therapies without an increase in bleeding; and in some reports, decreasing mortality. Importantly, PERTs are positively impacting outcomes by changing the paradigm of care for acute PE through global adoption by the health-care community.

Pulmonary Embolism Response Teams: Theory, Implementation, and Unanswered Questions

Pulmonary embolism (PE) continues to represent a significant health care burden and its incidence is steadily increasing worldwide. Constantly evolving therapeutic options and the rarity of randomized controlled trial data to drive clinical guidelines impose challenges on physicians caring for patients with PE. Recently, PE response teams have been developed and recommended to help address these issues by facilitating a consensus among local experts while advocating the management of acute PE according to each individual patient profile. In this review, we focus on the clinical challenges supporting the need for a PE response team, report the current evidence for their implementation, assess their impact on PE management and outcomes, and address unanswered questions and future directions.

Impact of pulmonary embolism response teams on acute pulmonary embolism: a systematic review and meta-analysis

BACKGROUND

The impact of pulmonary embolism response teams (PERTs) on treatment choice and outcomes of patients with acute pulmonary embolism (PE) is still uncertain.

OBJECTIVE

To determine the effect of PERTs in the management and outcomes of patients with PE.

METHODS

PubMed, Embase, Web of Science, CINAHL, WorldWideScience and MedRxiv were searched for original articles reporting PERT patient outcomes from 2009. Data were analysed using a random effects model.

RESULTS

16 studies comprising 3827 PERT patients and 3967 controls met inclusion criteria. The PERT group had more patients with intermediate and high-risk PE (66.2%) compared to the control group (48.5%). Meta-analysis demonstrated an increased risk of catheter-directed interventions, systemic thrombolysis and surgical embolectomy (odds ratio (OR) 2.10, 95% confidence interval (CI) 1.74-2.53; p<0.01), similar bleeding complications (OR 1.10, 95% CI 0.88-1.37) and decreased utilisation of inferior vena cava (IVC) filters (OR 0.71, 95% CI 0.58-0.88; p<0.01) in the PERT group. Furthermore, there was a nonsignificant trend towards decreased mortality (OR 0.87, 95% CI 0.71-1.07; p=0.19) with PERTs.

CONCLUSIONS

The PERT group showed an increased use of advanced therapies and a decreased utilisation of IVC filters. This was not associated with increased bleeding. Despite comprising more severe PE patients, there was a trend towards lower mortality in the PERT group.

The Pulmonary Embolism Response Team: Rationale, Operation, and Outcomes

The pulmonary embolism response team (PERT) is an institutionally based multidisciplinary team that is able to rapidly assess and provide treatment for patients with acute pulmonary embolism (PE). Intrinsic to the team's structure is a formal mechanism to execute a full range of medical, endovascular, and surgical therapies. In addition, the PERT provides appropriate multidisciplinary follow-up of patients. In the 10 years since the PERT was first introduced, it has gained acceptance in many centers in the United States and around the world. These PERTs have joined together to form an international association, called the PERT Consortium. The mission of this consortium is to advance the diagnosis, treatment, and outcomes of patients with PE. There is considerable evidence that the PERT model improves delivery and standardization of care of PE patients, particularly those patients with massive and submassive PE. However, it is not yet clear whether PERTs improve clinical outcomes. A large prospective database is currently being compiled by the PERT Consortium. Analysis of this database will likely further delineate the role of PERTs in the management of intermediate-to-high risk PE patients and, importantly, help determine in which PE patients PERT may improve clinical outcomes.

Characteristics and Outcomes of Patients Consulted by a Multidisciplinary Pulmonary Embolism Response Team: 5-Year Experience

(1) Background: Pulmonary embolism (PE) is the third most frequent acute cardiovascular condition worldwide. PE response teams (PERTs) have been created to facilitate treatment implementation in PE patients. Here, we report on the 5-year experience of PERT operating in Warsaw, Poland, with regard to the characteristics and outcomes of the consulted patients. (2) Methods: Patients diagnosed with PE between September 2017 and December 2021 were included in the study. Clinical and treatment data were obtained from medical records. Patient outcomes were assessed in-hospital, at a 1- and 12-month follow-up. (3) Results: There were 235 PERT activations. The risk of early mortality was low in 51 patients (21.8%), intermediate–low in 83 (35.3%), intermediate–high in 80 (34.0%) and high in 21 (8.9%) patients. Anticoagulation alone was the most frequently administered treatment in all patient subgroups (altogether 84.7%). Systemic thrombolysis (47.6%) and interventional therapy (52%) were the prevailing treatment options in high-risk patients. The in-hospital mortality was 6.4%. The adverse events during 1-year follow-up included five deaths, two recurrent VTE and two minor bleeding events. (4) Conclusions: Our initial 5-year experience showed that the activity of the local PERT facilitated patient-tailored decision making and the access to advanced therapies, with subsequent low overall mortality and treatment complication rates, confirming the benefits of PERT implementation.

Use of artificial intelligence in emergency radiology: An overview of current applications, challenges, and opportunities

The value of artificial intelligence (AI) in healthcare has become evident, especially in the field of medical imaging. The accelerated pace and acuity of care in the Emergency Department (ED) has made it a popular target for artificial intelligence-driven solutions. Software that helps better detect, report, and appropriately guide management can ensure high quality patient care while enabling emergency radiologists to better meet the demands of quick turnaround times. Beyond diagnostic applications, AI-based algorithms also have the potential to optimize other important steps within the ED imaging workflow. This review will highlight the different types of AI-based applications currently available for use in the ED, as well as the challenges and opportunities associated with their implementation.

Pharmacists as members of an interdisciplinary pulmonary embolism response team

Introduction

Pulmonary embolism response teams (PERTs) were developed to assist with diagnosis, risk stratification, and management of intermediate and high-risk pulmonary embolism (PE) and have been shown to reduce 90-day mortality. The pharmacist's role on the PERT is not well defined.

Objectives

Describe the pharmacist's role as a PERT member and determine if pharmacists can improve time to anticoagulation and promote use of low molecular weight heparin (LMWH) instead of unfractionated heparin (UFH).

Methods

A retrospective, observational study of adult patients with massive or submassive PE between January 2014 and May 2020. Patient demographics, clinical variables, anticoagulation treatment/timing, and pharmacist activities during PERT response were evaluated. Patients were divided into three groups for comparisons (pre-PERT vs post-PERT with a pharmacist vs post-PERT without a pharmacist). Wilcoxon rank-sum or Kruskal-Wallis test and chi-squared analysis were used for continuous and categorical data, respectively.

Results

A total of 573 patients were included (mean age 63.2 ± 15.6 years, 54% male, 78% submassive PE); 137 in the pre-PERT and 436 in the post-PERT groups. Within the post-PERT group, 305 patients (70%) had a pharmacist as a member of the PERT, of which 222 (73%) had a documented pharmacotherapy-related intervention/activity. Most (n = 178, 58%) involved a pharmacist facilitating ordering/administration of an anticoagulant/thrombolytic. Median time from diagnosis to anticoagulation was significantly reduced in the post-PERT groups (pre-PERT: 104 minutes [IQR 124.5], post-PERT with a pharmacist: 63 minutes [IQR 84], post-PERT without a pharmacist: 75.5 minutes [IQR 113], P = .0001). More patients in the post-PERT groups received LMWH compared to UFH when a pharmacist was involved vs without a pharmacist (69.5% vs 53.3%, P = .0019) and major bleeding events were reduced (pre-PERT: 14.6%, post-PERT with a pharmacist: 4.6%, and post-PERT without a pharmacist: 9.9%, P = .0013).

Conclusion

Pharmacists have an active role on the PERT and their involvement was associated with a shorter diagnosis to anticoagulation time, increased LMWH use, and fewer major bleeding events.

Single versus multiple and incidental versus symptomatic subsegmental pulmonary embolism: clinical characteristics and outcome

It remains unexplored if the clinical picture and outcome of subsegmental pulmonary embolism (SSPE) differ between single versus multiple, and incidental versus symptomatic embolism. Consecutive patients anticoagulated for SSPE at the Mayo Thrombophilia Clinic (03/01/2013-12/31/2020) were followed forward to assess venous thromboembolism (VTE) recurrence, mortality, major bleeding, and clinically relevant non-major bleeding (CRNMB); expressed as a rate per 100 person-years. Among 3878 VTE patients, 1541 had pulmonary embolism including 224 (14.6%) with SSPE either single (n = 139) or multiple (n = 85; 46 bilateral and 39 unilateral emboli); 134 had incidental and 90 symptomatic SSPE. Patients with single were less often symptomatic and less often had coexisting DVT than multiple SSPE. Patients with incidental had a two-fold higher frequency of cancer compared to symptomatic SSPE. During the study period, 1 patient with single and 2 with multiple SSPE had VTE recurrence (rate of 1.14 vs 3.63, p = 0.280). Single SSPE patients experienced 2 episodes of major bleeding (rate of 2.36) while the multiple SSPE group had no major bleeding. Seven patients in each group had CRNMB events (rate of 8.20 vs 13.58 for single and multiple SSPE, respectively, p = 0.282). Patients with single SSPE had a higher death rate compared to multiple SSPE (43.07 vs 22.22, p = 0.031) but no difference was noted after adjusting for cancer (p = 0.388). Also, incidental had similar clinical outcomes to symptomatic SSPE.Interpretation Anticoagulated SSPE patients with single and multiple as well as incidental and symptomatic have a different clinical profile but similar clinical outcomes.

Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE)

OBJECTIVE

Develop and validate a prognostic model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria.

METHODS

We used prospective registry data from six emergency departments. The primary composite outcome was death or deterioration (respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension, and rescue reperfusion intervention) within 5 days. Candidate predictors included laboratory and imaging right ventricle (RV) assessments. The prognostic model was developed from 935 PE patients. Univariable analysis of 138 candidate variables was followed by penalized and standard logistic regression on 26 retained variables, and then tested with a validation database (N = 801).

RESULTS

Logistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected/confirmed systemic infection, syncope, medico-social admission reason, abnormal heart rate, and two points for creatinine greater than 2.0 mg/dL. In the development database, 22.4% had the primary outcome. Prognostic accuracy of logistic regression model versus PE-SCORE model: 0.83 (0.80, 0.86) vs. 0.78 (0.75, 0.82) using area under the curve (AUC) and 0.61 (0.57, 0.64) vs. 0.50 (0.39, 0.60) using precision-recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 (0.73, 0.81) and AUCpr 0.63 (0.43, 0.81). As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had ≥ 69.6% outcomes. In the validation dataset, PE-SCORE zero had 8% outcome [no deaths], whereas all patients with PE-SCORE of six and above had the primary outcome.

CONCLUSIONS

PE-SCORE model identifies PE patients at low- and high-risk for deterioration and may help guide decisions about early outpatient management versus need for hospital-based monitoring.

AngioVac aspiration of right atrial cardiac pacemaker lead-associated thrombus with concurrent PE under fluoroscopic and transesophageal echocardiographic guidance: a multidisciplinary collaboration for improved patient outcome

In the U.S., pulmonary embolism (PE) is a common cause of cardiovascular death. Right heart thrombus (RHT) occurs in approximately 4% of patients with PE, and when concurrent is associated with increased 30-day PE-related and all-cause mortality. The consensus on optimal management of acute massive or high-risk PE is unclear, and even less so for concurrent RHT. In this report, we review a successful multidisciplinary coordination of vacuum-assisted thrombectomy (VAT) of a complex pacemaker lead-associated RHT in a patient with concurrent acute PE and significant comorbidities, using the AngioVac system (Vortex Medical, Norwell, MA). VAT is a reasonable treatment option that should be considered particularly for patients who are poor surgical or thrombolytic candidates. Procedural success and patient outcomes can be further optimized through multidisciplinary collaboration such as with the Pulmonary Embolism Response Team (PERT) model.

Association of Thrombin-Activatable Fibrinolysis Inhibitor with Acute Pulmonary Embolism

BACKGROUND

 Thrombin-activatable fibrinolysis inhibitor (TAFI) inhibits fibrinolysis and high levels may have an association with thrombosis. The aim of the current study was to investigate the association of TAFI antigen levels with pulmonary thromboembolism (PTE).

PATIENTS AND METHODS

 A case-control study was conducted with 29 patients with PTE and 17 age- and gender-matched control individuals. Plasma levels of TAFI were measured at the time of diagnosis, then at 3 and 6 months after the event.

RESULTS

 Initial TAFI levels (%) were higher in patients with PTE than in the control group Initial TAFI levels (%) were higher in patients with PTE than in the control group (190,0 [65,0-250,0] vs 133,0 [83,0-153,0]; p = 0.003). TAFI levels significantly decreased at the third and sixth months after initial diagnosis (p < 0.05). The percentage reductions in TAFI levels were 12 and 36.8% at 3 and 6 months, respectively. The Odss ratio (OR) of TAFI level for PTE was found to be 1.024 (95% CI: 1.007-1.040; p = 0.005). There was no significant correlation of initial TAFI levels with age, gender, smoking status, history of thrombosis, pulmonary artery pressure, and D-dimer levels (p > 0.05). In the sixth month of treatment, patients with residual thrombosis were seen to have similar baseline levels and reductions of TAFI as patients without residual thrombosis (p > 0.05).

CONCLUSION

 The result of this study suggests that high TAFI levels may have a role in the occurrence of PTE without impact on treatment outcome.

A 44-Year-Old Woman With Chest Pain and Dyspnea

CASE PRESENTATION

A 44-year-old woman with a medical history of anti-phospholipid antibody syndrome complicated by recurrent pulmonary emboli with subsequent chronic hypoxic respiratory failure (3 L/min oxygen baseline) presented to the ED with 2 to 3 weeks of shortness of breath and pleuritic chest pain that radiated to the center of her back. These symptoms were accompanied by an increase in her oxygen requirement from 3 L/min to 6 L/min. She also reported nausea, vomiting, lightheadedness, and dizziness for the same period. The patient had two prior pulmonary emboli in the same year, which prompted a hypercoagulable workup, ultimately revealing a diagnosis of antiphospholipid antibody syndrome. The second pulmonary embolus occurred while the patient was on coumadin, though achieving a therapeutic international normalized ratio was challenging. At the recommendation of the Hematology Department, she was transitioned to systemic anticoagulation with low-molecular-weight heparin (LMWH) at a dose of 1.5 mg/kg twice daily, which was her regimen at the time of admission. The patient confirmed total compliance with her anticoagulation therapy, and she denied any recent travel or long periods of being sedentary. She was up to date on her age-appropriate cancer screening, without any evidence of active malignancy.

Impact and role of pulmonary embolism response teams in venous thromboembolism associated with COVID-19

Venous thromboembolism associated with COVID-19, particularly acute pulmonary embolism, may represent a challenging and complex clinical scenario. The benefits of having a multidisciplinary pulmonary embolism response team (PERT) can be important during such a pandemic. The aim of PERT in the care of such patients is to provide fast, appropriate, multidisciplinary, team-based approach, with the common goal to tailor the best therapeutic decision making, prioritizing always optimal patient care, especially given lack of evidence-based clinical practice guidelines in the setting of COVID-19, which potentially confers a significant prothrombotic state. Herein, we would like to briefly emphasize the importance and potential critical role of PERT in the care of patients in which these two devastating illnesses are present together.

Thromboembolic Complications of SARS-CoV-2 and Metabolic Derangements: Suggestions from Clinical Practice Evidence to Causative Agents

Severe Acute Respiratory Syndrome (SARS) Coronavirus (CoV)-2 is a recently identified positive sense single-strand RNA (ssRNA) β-coronavirus. The viral spike proteins infect human hosts by binding to the cellular receptor angiotensin-converting enzyme 2 (ACE2). The infection causes a systemic illness involving cell metabolism. This widespread involvement is implicated in the pathophysiology of the illness which ranges from mild to severe, requiring multi organ support, ranging from oxygen supplementation to full cardiovascular and respiratory support. Patients with multiple co-existing comorbidities are also at a higher risk. The aim of this review is to explore the exact mechanisms by which COVID-19 affects patients systemically with a primary focus on the bleeding and thrombotic complications linked with the disease. Issues surrounding the thrombotic complications following administration of the ChAdOx1 nCoV-19 (Astra-Zeneca-Oxford) vaccine have also been illustrated. Risk stratification and treatment options in these patients should be tailored according to clinical severity with input from a multidisciplinary team.

Advanced therapies for pulmonary embolism

PURPOSE OF REVIEW

Treatment options for managing patients with acute pulmonary embolism are rapidly evolving. In this review, we discuss the supporting evidence and implementation strategies for these advanced therapeutic modalities.

RECENT FINDINGS

We review the recent data supporting systemic and catheter directed thrombolytic therapies, mechanical embolectomy, use of extracorporeal membrane oxygen support, and pulmonary embolism response teams in managing patients with acute pulmonary embolism. We discuss the major professional society recommendations regarding their implementation.

SUMMARY

A review of advanced therapies for pulmonary embolism.

Trends in Mortality of Acute Pulmonary Embolism

Despite substantial advances in the diagnosis and management, pulmonary embolism (PE) continues to be a significant cause of mortality. In this article, we provide a concise overview of the evolution of worldwide mortality trends related to PE. Despite the data being derived mainly from observational studies, there is a clear trend toward decreasing mortality over time from PE. Whether this truly represents a treatment effect or is more related to increased diagnosis of small PEs is not fully clear. Modern approaches to PE management such as the PE response teams have the potential to further reduce the mortality from PE.

Pulmonary Embolism Response Team activation during the COVID-19 pandemic in a New York City Academic Hospital: a retrospective cohort analysis

Coronavirus disease 2019 (COVID-19) is associated with increased rates of deep vein thrombosis (DVT) and pulmonary embolism (PE). Pulmonary Embolism Response Teams (PERT) have previously been associated with improved outcomes. We aimed to investigate whether PERT utilization, recommendations, and outcomes for patients diagnosed with acute PE changed during the COVID-19 pandemic. This is a retrospective cohort study of all adult patients with acute PE who received care at an academic hospital system in New York City between March 1st and April 30th, 2020. These patients were compared against historic controls between March 1st and April 30th, 2019. PE severity, PERT utilization, initial management, PERT recommendations, and outcomes were compared. There were more cases of PE during the pandemic (82 vs. 59), but less PERT activations (26.8% vs. 64.4%, p < 0.001) despite similar markers of PE severity. PERT recommendations were similar before and during the pandemic; anticoagulation was most recommended (89.5% vs. 86.4%, p = 0.70). During the pandemic, those with PERT activations were more likely to be female (63.6% vs. 31.7%, p = 0.01), have a history of DVT/PE (22.7% vs. 1.7%, p = 0.01), and to be SARS-CoV-2 PCR negative (68.2% vs. 38.3% p = 0.02). PERT activation during the pandemic is associated with decreased length of stay (7.7 ± 7.7 vs. 13.2 ± 12.7 days, p = 0.02). PERT utilization decreased during the COVID-19 pandemic and its activation was associated with different biases. PERT recommendations and outcomes were similar before and during the pandemic, and led to decreased length of stay during the pandemic.

The COVID-19 Pandemic: Disproportionate Thrombotic Tendency and Management Recommendations

COVID-19 is an infectious disease caused by the SARS COV-2 virus. Patients with COVID-19 are susceptible to thrombosis due to excessive inflammation, platelet activation, endothelial dysfunction, and circulatory stasis, resulting in an increased risk of death due to associated coagulopathies. In addition, many patients receiving antithrombotic therapy for pre-existing thrombotic diseases can develop COVID-19, which can further complicate dose adjustment, choice and laboratory monitoring of antithrombotic treatment. This review summarizes the laboratory findings, the prohemostatic state, incidence of thromboembolic events and some potential therapeutic interventions of COVID-19 associated coagulopathy. We explore the roles of biomarkers of thrombosis and inflammation according to the severity of COVID-19. While therapeutic anticoagulation has been used empirically in some patients with severe COVID-19 but without thrombosis, it may be preferable to provide supportive care based on evidence-based randomized clinical trials. The likely lifting of travel restrictions will accelerate the spread of COVID-19, increasing morbidity and mortality across nations. Many individuals will continue to receive anticoagulation therapy regardless of their location, requiring on-going treatment with low-molecular weight heparin, vitamin K antagonist or direct-acting anticoagulants.

Massive Pulmonary Embolism with Cardiac Arrest during Routine Tibial Bypass Surgery

We report the case of a massive pulmonary embolism with intraoperative cardiac arrest in a 48-year-old male during routine surgical tibial bypass successfully managed by catheter-based interventions. Our experience supports the trending shift in pulmonary embolism therapy guidelines to include endovascular approaches and emphasizes the need for vascular surgeons to adapt their training protocols.