Welcome to the first episode of PERTCast, the official podcast of the PERT Consortium!

Episode 1: Oren Friedman interviews Vic Tapson about risk stratification of the pulmonary embolism patient.

Oren Friedman MD Associate Director, Cardiac Surgery ICU Pulmonary Critical Care Cedars-Sinai Medical Center

Victor Tapson MDProfessor of MedicineDirector, Venous Thromboembolism and Pulmonary Vascular Disease Research ProgramAssociate Director, Pulmonary and Critical Care SectionCedars-Sinai Medical Center

PE risk stratification Pearls: history and classifications.

• Patient's appearance and vitals (initial and trend) are most important parts of risk stratification algorithm.
• Syncope can have a wide differential. Syncope in setting of PE can have significant consequences.
• Patient resting comfortably can be reassuring, but at the same time ask- what happens on exertion, to gauge the severity of symptoms (i.e. dizziness, near syncope etc.)
• Profound hypoxemia is under recognized in PE classification.
• European Society of Cardiology (ESC) integrates PESI, and sPESI score that is much more practical way of PE classification.
• ESC classification divide PE into Intermediate PE (Submassive PE) in to two categories- Intermediate high risk (positive sPESI score, RV dysfunction and biomarker positivity) or Intermediate low risk (Positive sPESI score, and RV dysfunction or biomarker positivity).
• PE classification is heterogeneous, patient's hemodynamics can evolve, so will be their risk stratification score.

Biomarkers in PE risk stratification:

• Troponin more sensitive than BNP. Be careful for false positives (elevated BNP in chronic heart failure)
• Lactic acid can provide prognostic information in setting of PE.

CTA based risk stratification:

• Contrast reflux into IVC/Liver
• RV/LV ratio >0.9
• Clot burden, 40% occlusion of pulmonary circulation can be associated with high PE related mortality.

Echo based risk stratification:

• Normal RV can't generate systolic pressure in the excess of 50-60 mm Hg.
• Elevated PA systolic pressure >70-80 mm HG suggest chronic component of RV failure
• RV need to have good systolic function to generate high PA pressure
• TAPSE is not the holy grail of RV dysfunction, interpret with caution.

Residual DVT

• Extensive DVT (above knee) with higher risk PE have worse outcomes.
• Patient activity (few days to weeks) should be restricted.
• IVC filter should not be considered in every case of PE with DVT.

Treatment Pearls:

• Every patient with acute PE should be promptly anticoagulated.
• Change in vital trends or persistently abnormal vital signs may help in consideration of advance reperfusion strategies in same PE category.

Take home message:

• Look at patient's appearance + Vitals (HR, RR) and add other objective measures (sPESI, Biomarkers, imaging) + Residual clot burden in risk stratification.
• Activate the multidisciplinary PERT to leverage input from local experts.

References:

• Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35(43):3033-69, 3069a-3069k.
• Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383-9.
• Van der meer RW, Pattynama PM, Van strijen MJ, et al. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology. 2005;235(3):798-803.
• Prandoni P, Lensing AW, Prins MH, et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016;375(16):1524-1531.
• Becattini C, Cohen AT, Agnelli G, et al. Risk Stratification of Patients With Acute Symptomatic Pulmonary Embolism Based on Presence or Absence of Lower Extremity DVT: Systematic Review and Meta-analysis. Chest. 2016;149(1):192-200.
• Grau E, Tenías JM, Soto MJ, et al. D-dimer levels correlate with mortality in patients with acute pulmonary embolism: Findings from the RIETE registry. Crit Care Med. 2007;35(8):1937-41.