Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension

Abstract

Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.

Early Use of Echocardiography in Patients With Acute Pulmonary Embolism: Findings From the RIETE Registry

“…Mobile right heart thrombi may carry an even higher risk 16. Despite the elevated risk, clinical management of these patients remains controversial, with guidelines being silent or equivocal about optimal management 11, 17, 18. Thrombolysis carries the potential risk of further pulmonary emboli as a result of partial dissolution of the thrombi 19.…”

Association Between Electrocardiographic Findings, Right Heart Strain, and Short‐Term Adverse Clinical Events in Patients With Acute Pulmonary Embolism

“…The AHA recommends risk stratification of acute PE patients based on RHS. 3 Certain ECG characteristics have been shown to be associated with RHS but typically are not incorporated in the risk-stratification models. 4,16 In this study, we found 3 ECG characteristics independently associated with RHS: TWI in leads V 1 through V 3 , S wave in lead I, and sinus tachycardia.…”

“…2 The American Heart Association (AHA) consensus guidelines recommend risk stratification of PE patients to guide appropriate and timely management and disposition. 3 This study was funded by an award from the Harvard Milton Fund. The funding agency had no influence on the design or conduct of the study and played no role in interpreting the results or drafting the manuscript.…”

Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department

“…The parasternal long axis was examined for pericardial effusion, visual estimation of qualitative LV function, signs of RV dilation (RV/LV end diastolic diameter > 0.7) [17]. The apical four-chamber view was examined for pericardial effusion, qualitative LV function and signs of RV dilation (RV/LV end diastolic diameter > 0.9) [18][19][20].…”