Anticoagulant treatment for acute pulmonary embolism: a pathophysiology-based clinical approach

Abstract

The management of patients with acute pulmonary embolism is made challenging by its wide spectrum of clinical presentation and outcome, which is mainly related to patient haemodynamic status and right ventricular overload. Mechanical embolic obstruction and neurohumorally mediated pulmonary vasoconstriction are responsible for right ventricular overload. The pathophysiology of acute pulmonary embolism is the basis for risk stratification of patients as being at high, intermediate and low risk of adverse outcomes. This risk stratification has been advocated to tailor clinical management according to the severity of pulmonary embolism.Anticoagulation is the mainstay of the treatment of acute pulmonary embolism. New direct oral anticoagulants, which are easier to use than conventional anticoagulants, have been compared with conventional anticoagulation in five randomised clinical trials including >11 000 patients with pulmonary embolism. Patients at high risk of pulmonary embolism (those with haemodynamic compromise) were excluded from these studies. Direct oral anticoagulants have been shown to be as effective and at least as safe as conventional anticoagulation in patients with pulmonary embolism without haemodynamic compromise, who are the majority of patients with this disease. Whether these agents are appropriate for the acute-phase treatment of patients at intermediate-high risk pulmonary embolism (those with both right ventricle dysfunction and injury) regardless of any risk stratification remains undefined. @ERSpublications New oral anticoagulants are efficacious and safe in haemodynamically stable patients with acute pulmonary embolism http://ow.ly/I2iP5

Developing a scoring tool to estimate the risk of deterioration for normotensive patients with acute pulmonary embolism on admission

“…Our results are consistent with the Bova score, as a decreased systolic pressure (90-100 mmHg) and an elevated heart rate (≥ 110 beats/min) were risk factors for adverse outcomes. In normotensive patients with acute PE that is deteriorating, tachycardia and relative hypertension are compensatory and neurohumoral responses to a low left heart output [5,27,28]. However, we found that elevated NT-pro BNP concentrations were a signi cant risk factor, but elevated c-Tn I concentrations were not, which con icts with the 2019 ESC algorithm and Bova score.…”

“…To expand the utility of our tools, we did not consider the underlying disease, which can predict a poor prognosis in acute PE [29]. In this context, elevated NT-pro BNP and c-Tn I concentrations are caused by myocyte stretching [27]. However, NT-pro BNP can re ect the patient's current state and also underlying disease, such as chronic heart failure [28,30], although c-Tn I concentrations do not.…”

Developing a scoring tool to estimate the risk of deterioration for normotensive patients with acute pulmonary embolism on admission 

“…Our results are consistent with the Bova score as a decreased systolic pressure (90-100 mmHg) and an elevated heart rate (≥110 beats/min) were risk factors for adverse outcomes. In normotensive patients with acute PE that is deteriorating, tachycardia and relative hypertension are compensatory and neurohumoral responses to a low left heart output [26][27][28]. However, we found that elevated NT-pro BNP concentration was included in the nal scoring tool for predicting adverse outcomes, and c-Tn I concentration was not included.…”

Initial Experience with Non-Sternotomy Minimally Invasive Pulmonary Embolectomy with Thoracoscopic Assistance

“…11 Although systemic and catheter-directed anticoagulation has arisen as the treatment of choice for most cases of PE, the effectiveness of these approaches remains suboptimal in cases of massive PE. 3,12 Significant complications of anticoagulation and thrombolysis exist. These include hemorrhagic stroke, hemothorax, and hematoma with major bleeding episodes occurring in up to 20% of patients treated with these modalities.…”