Contemporary Management of Pulmonary Embolism

Lowell I. Gerber M.D.

Associate Professor of Medicine

KCOM

PULMONARY EMBOLISM

• Estimated 650,000 cases annually in the US

• Third most common cause of death in US– 50,000 to 200,000 deaths per year

• 15% of all in-hospital deaths

• Difficult to diagnose

• Approx. 10% of patients in whom diagnosis is established die within first 60 minutes

Estimated 10+% of all PE

3-7X increased mortality over non-massive PEUPET 36% vs 5%ICOPER 58% vs 15%MAPPET 31%

MASSIVE PULMONARY EMBOLISM

PULMONARY EMBOLISMPATHOLOGY

PULMONARY EMBOLISMPATHOPHYSIOLOGY

THE SPECTRUM OF PULMONARY EMBOLISM

Right Ventricular

Dysfunction

Hemodynamic

Instability

Stable Hemodynamics and Cardiac Function

CLINICAL RISK FACTORS FOR VTE

• AGE > 40• MAJOR SURGERY OR

TRAUMA• IMMOBILIZATION• VENOUS STASIS• OBESITY• DIABETES• FRACTURE• VARICOSE VEINS

• CHF , MI, CVA• PRIORHX VTE HIP• PREGNANCY /

POSTPARTUM• CONTRACEPTIVES• CANCER• ANTIPHOSPHOLIPID

AB SYNDROME

HERITABLE RISK FACTORS FOR VTE

• FACTOR V LEIDEN MUTATION

• HYPERHOMOCYSTEINEMIA

• PROTEIN C DEFICIENCY

• RESISTANCE TO ACTIVATED PROTEIN C

• PROTEIN S DEFICIENCY

• ANTITHROMBIN III DEFICIENCY

HERITABLE RISK FACTORS FOR VTE

• PROTHROMBIN MUTATION G20210A

• HEPARIN COFACTOR II

• DYSFIBRINOGENEMIA

• DYSPLASMINOGENEMIA

RISK STRATIFICATIONVARIABLE HAZARD RATIO (95% CI)

Age >70 years 1.6 (1.1-2.3)

COPD 1.8 (1.2-2.7)

Systolic blood pressure <90mmHg 2.9 (1.7-5.0)

Right ventricular hypokinesis 2.0 (1.3-2.9)

Congestive Heart Failure 2.4 (1.5-3.7)

Cancer 2.3 (1.5-3.5)

Respiratory rate <20/min 2.0 (1.2-3.2)

Goldhaber, et al. Lancet.353:1386-89; 24 Apr 1999

RISK STRATIFICATIONUsing a Clinical Decision Rule

• Clinical signs and symptoms of DVT 3.0• Alternative diagnosis less likely than PE 3.0• Heart rate >100/min 1.5• Immobilization (>3days) or surgery in 4wks 1.5• Previous PE or DVT 1.5• Hemoptysis 1.0• Malignancy (Rxing or Rxed in last 6 mos) 1.0

>4 pts: Clinical probability of PE is likely4 or less pts: Clinical probability of PE is unlikely

Wells, et al Thromb Haemost 2000;83:416-420

MORTALITY PE/DVT IN ELDERLY

INHOSPITAL 1 YEAR

21% / 3% 39% / 21%

Kniffin et al. Arch Intern Med. 1994 Apr 25

CLINICAL PROFILE PE

STEIN, P.D. ET AL. CHEST 100:598, 1991

SYMPTOMS FREQUENCY (%)

DYSPNEA 73

PLEURITIC PAIN 66

COUGH 37

LEG SWELLING / PAIN 28 / 26

SIGNS FREQUENCY (%)

TACHYPNEA (>20/MIN) 70

RALES 51

TACHYCARDIA 30

S4 / INCREASED S2 24 / 23

CXR

• PULMONARY VASCULATURE

ENLARGED RIGHT DESCENDING PULMONARY ARTERY

WEDGE-SHAPED INFILTRATE

OFTEN NORMAL

ELECTROCARDIOGRAM PULMONARY EMBOLISM

T-wave inversion in leads III, aVF, or in leads V1-V4QS in leads III and aVF

Incomplete or complete right bundle branch block

QRS axis > 90 or indeterminate axisTransition zone shift to V5

ELECTROCARDIOGRAM PULMONARY EMBOLISM

• S1,Q3,T3 most specific• Normal or Sinus Tachycardia

most frequent

LABORATORY TESTING D-DIMER ELISA

• Sensitive but nonspecific test for PE

• High negative predictive value when concentrations <500ng/ml

• Omit if high clinical suspicion or patient with systemic illness

Goldhaber, et al. JAMA. 1993. 270:2819-2822

Bounameaux, et al. Thromb Haemost. 1994; 71; 1-6

LABORATORY TESTINGBioMarkers in Pulmonary Embolism

LABORATORY TESTINGBioMarkers in Pulmonary Embolism

BNP• Normal BNP: Benign Prognosis

• Elevated BNP associated with adverse outcome

• Other causes of elevated BNP in RV pressure overload:– Primary pulmonary hypertension

– Chronic thromboembolic pulmonary hypertension

– Chronic lung disease

Circulation. 2003 Apr 1;107(12):1576-8

LABORATORY TESTINGBioMarkers in Pulmonary Embolism

Troponin

LABORATORY TESTINGBioMarkers in Pulmonary Embolism

Troponin

LABORATORY TESTINGBioMarkers in Pulmonary Embolism

Troponin• In acute pulmonary embolism elevated troponin levels have been shown to

predict an adverse outcome.

• Serum troponin levels should help stratify patients with submassive acute pulmonary embolism into a group in which aggressive medical or surgical intervention would be considered

Curr Opin Pulm Med. 2003 Sep;9(5):374-7.

V/Q SCAN

NORMAL PERFUSION

ABNORMAL PERFUSION

NORMAL- AND HIGH-PROBABILITY SCANS ARE CONSIDERED DIAGNOSTIC

PIOPED: PREDICTIVE VALUE V/Q SCAN

SCAN CATEGORY CLINICAL SUSPICION

80-100% 20-79% 0-19%

HIGH 96% 88% 56%

INTERMEDIATE 66% 28% 16%

LOW 40% 16% 4%

PIOPED INVESTIGATORS. JAMA.1990; 263: 2753-2759

PULMONARY ANGIOGRAPHY

• Gold Standard• Death in 0.5%• Major, nonfatal

complications in 1%• Visualizes distal

segments• Role in primary

therapy for PE

ANGIOGRAPHIC SEVERITY SCORING

Miller, et al. Amer Journ Roent,Rad Therapy & Nuc Med. 125(4):895-9, 1975 Dec.

Multi Slice CT

92 % SENSITIVITY , 95% SPECIFICITY COMPARED TO ANGIOGRAPHY OR TO HIGH-PROB OR NORMAL SCINTIGRAM (3rd generation scanner, 1mm slice thickness)

van Rossum,et al.Radiology.1996;201:467-70

Multi Slice CT

Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining

Clinical Probability, D-Dimer Testing, and Computed Tomography

JAMA 2006; 295:172-179January 11, 2006

Writing Group for the Christopher Study Investigators

Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining

Clinical Probability, D-Dimer and CT

VTE Events During 3 month F/U in 3138 patients

PE unlikely and Nl D-Dimer 1028 5(0.5) 0(0)

PE excluded by CT 1436 18(1.3) 7(0.5)– CT Normal 764 9(1.2) 3().4)

– CT alternative Dx 672 9(1.3) 4(0.6)

PE diagnosed by CT 674 20(3) 11(1.6)

mortality 7.2% (55)

Inconclusive CT 20 2+by V/Q, 1/18 non-fatal PE

mortality 5% (1/20)

CT indicated but not done 50 3+by V/Q, 2 had DVT by CUS

1/45 fatal PE,

mortality 14% (7/50)

Pts Total VTE Fatal PE

ECHOCARDIOGRAPHY PULMONARY EMBOLISM

• Direct visualization of thrombus

• Right ventricular dilatation & hypokinesis (except apex, McConnell’s sign)

• Abnormal interventricular septal motion

• Tricuspid valve regurgitation >2.8 m/s

• Lack of decreased inspiratory collapse of inferior vena cava

TRANS ESOPHAGEAL ECHOCARDIOGRAPHYAND PATENT FORAMEN OVALE

in PULMONARY EMBOLISM

Patent foramen ovale detected on TEE is an important predictor of adverse outcome in patients with major pulmonary embolism.

These patients had a death rate of 33% as opposed to 14% in patients without PFO

There is significantly higher incidence of ischemic stroke (13% versus 2.2%; P=.02) and peripheral arterial embolism (15 versus 0%; P<.001).

Overall, the risk of a complicated in-hospital course was 5.2 times higher in this patient group (P<.001).

Circulation. 1999 Jun 29;99(25):3323.

 

RV OVERLOAD

DIASTOLE SYSTOLE

RV DILATATION & ABNORMAL SEPTAL MOTION

MORTALITY RV DYSFUNCTION

Goldhaber, et al. Lancet. 353: 1386-89;24 April 1999

RV HYPOKINESIS

NO RV HYPOKINESIS

PRIMARY THERAPY VS SECONDARY PREVENTION

HEPARIN

NORMAL BP RV DYSFUNCTION SBP<90

THROMBOLYSIS

MECHANICAL INTERVENTION

Heparin Anticoagulation

• While diagnostic work-up in progress begin with UFH 80/kg IV bolus, then 18 U/kg per hour, target PTT 60-80 secs

• Rapid reversibility for patients who may require thrombolysis, thrombectomy, or who have alternative diagnosis

Heparin Anticoagulation

• For stable patients recommendations include either weight based protocols for UFH, or

• Low Molecular weight heparin, trials suggest better efficacy with less bleeding

• LMWH can be considered as alternative to oral anticoagulation

• Monitor platelet counts and CBC

• When HIT complicates therapy, use direct thrombin inhibitors– Argatroban– Lepirudin

Low Molecular Weight Heparins

THROMBOLYSISUNSTABLE PATIENTS

Heparin Strep/heparin

Survived 0 4

Dead 4 0

Jerges-Sanchez et al. J Thromb Thrombolysis 1995;2:227-229

Cardiac CT

Cardiac CT

THROMBOLYSIS RV DYSFUNCTION

Goldhaber et al. The Lancet 341:8844; 507-511, Feb 27 1993

THROMBOLYSIS STABLE MAJOR PE

Konstantinides S et al. Circulation. 1997;96:882-888

THROMBOLYSIS STABLE MAJOR PE

ONLY INDEPENDENT PREDICTOR OF SURVIVAL (719 PATIENTS)

Konstantinides et al. Circulation.1997;96:882-888

Management Strategies and Prognosis of Pulmonary Emobolism

MAPPET-3• Rt-PA + Heparin vs Heparin alone

• 256 patients with RV dysfunction but no hypotension/shock

• Primary endpoint: death or escalation of therapy eg: need for catecholamine, thrombolytics, CPR, intubation, embolectomy

• Primary endpoint achieved in 25% of patients with heparin alone vs 10% patients with rt-PA plus heparin (p=0.006)

• No ICH in the controlled trial

• ICH occurred in 3.0% of 304 patients receiving thrombolytics in registry (2454 pts)

NEJM 2002 347:1143

THROMBOLYSIS CONTRAINDICATIONS

• Active internal bleed• CVA• Diastolic HTN>110 • Surgery < 10 days• CPR• Pregnancy• Post-partum < 10 days• Trauma

THROMBOLYSIS COMPLICATIONS

• Major bleeding frequency after noninvasive diagnosis= 4.2%

• Major bleeding frequency after invasive diagnosis= 14%

• Fewer complications would occur with noninvasive management

Stein et al.Annals of Internal Medicine.121:313-317, Sept 1994

THROMBOLYSISIN-VITRO

• Streptokinase has slowest rate of clot lysis.

• Urokinase has intermediate rate of clot lysis, but most fibrinolytic specificity.

• rt-PA improved efficacy early, but rt-PA and urokinase difference dissipated after 30 min.

Ouriel K, et al. J Vasc Surg. 1995; 22: 593-597

Thrombolytic Regimens for Pulmonary Embolism

• Streptokinase: 250K loading dose IV over 30min followed by 100K U/hr for 24 hr (FDA ok)

• Alteplase(t-PA): 100mg, peripheral IV infused over 2 hrs (FDA ok)

• Urokinase 2000 U/lb IV loading dose over 10 min, then 2000 U/lb per hour for 12 to 24 hours (FDA ok)

• Reteplase (retavase): 10U IV over 2min, then 30 min later 10U over 2 min

Potential Indications for Thrombolytic Therapy for VTE

Commonly Accepted• Presence of hypotension or hemodynamic instability

Careful Case Selection• Presence of severe hypoxemia

• Substantial perfusion defect V/Q or thrombus burden CT

• Right ventricular dysfunction associated with PE

• Concomitant extensive deep vein thrombosis

• Free-floating RA/RV thrombus

• Patent Foramen Ovale (PFO) / paradoxical embolus

PERCUTANEOUS

PERCUTANEOUS INTERVENTION

• 1969- Greenfield: Vacuum pump embolectomy

• 1994- Mazeika: Percutaneous catheter fragmentation

• 1994- Dievart: Angiocor Thrombolizer

• 1995- Scmitz-Rode: Pigtail catheter fragmentation

• 1996- Uflacker: Amplatz thrombectomy device

• 1997- Koning: Rheolytic thrombectomy catheter

UROKINASE INTRAPULMONARY INFUSION

• 26 patients with PE received intrapulmonary arterial infusions of urokinase.

• 9/26 had systemic thrombolytic contraindications.

• 20 pts returned to baseline state, 1 minimal change, 5 deaths

McCotter,C.J. et al. Clin. Cardiol.22, 661-664 (1999)

PULMONARY INTRATHROMBUSINFUSION

THROMBOLYSIS AND FRAGMENTATION

IVC FILTERS

TWO PRINCIPAL INDICATIONS– Absolute contraindication to anticoagulation or

complication of anticoagulation therapy.

– Recurrent PE despite adequate duration and level of anticoagulation, or patient not likely to

survive a recurrent PE because of tenuous hemodynamic status and iliofemoral thrombus burden.

IVC FILTERS

• Do not prevent further thrombosis

• Serve as a “nidus” for recurrent thrombus

• Re-hospitalization within 1 year of filter placement for recurrent VTE 2.6 X control.

Arch Intern Med 2000; 160:2033

CURRENT PERMANENT IVC FILTERS

Greenfield

Bird’s Nest

Simon Nitinol

Vena Tech

Stainless steel

Titanium

RETRIEVABLE VENA CAVA FILTERS

• Recovery Nitinol Filter

• Gunther Tulip Filter

• OptEase Filter

Recovery Nitinol Filter

• Bard Peripheral Vascular, Tempe, AZ

• First FDA approved retrievable filter has no barbs for fixation, and therefore has a much longer potential window for retrieval.

• One group has reported successful retrieval of filters as long as 134 days after insertion. There was, however, one filter that migrated after clot capture.

• This emphasizes the one minor weakness of retrievable filters with extended placement times; these filters may have less surface area of contact with the vena cava to avoid tissue ingrowth and fixation.

(Cook Inc., Bloomington, IN) has perhaps the widest experience in both the US and Europe.

There are several reports in the literature supporting its value as a temporary filter

It has the capability of deployment from either a femoral or jugular route. It must be retrieved from a jugular vein approach.

Most authors recommended retrieval within 14 days.

Gunther Tulip Filter

Cordis Endovascular, a Johnson & Johnson company, Miami, FL

Has a unique self-centering design that provides dual-level filtration.

It can be deployed from both the transfemoral and transjugular approaches using the same kit.

It is the only potentially retrievable filter that is recovered from a femoral vein approach and requires a small retrieval system (10F guiding catheter)

OptEase Filter

NEW AND PROPHYLACTIC APPLICATIONSOF IVC FILTERS

Trauma and major orthopedic surgery will most likely encompass the greatest use of retrievable vena cava filters

With the increasing number of obese patients undergoing major operations and bariatric surgery, the use of retrievable filters will

continue to grow.

Ongoing prospective studies will probably support elevated body mass index as a major predictor of pulmonary embolism and will have a tremendous impact on the future of retrievable vena cava filters.

NEW AND PROPHYLACTIC APPLICATIONSOF IVC FILTERS

• Patients with DVT but no PE– Reduced cardiopulmonary function, would not

tolerate a PE– Free-floating DVT despite adequate anticoag– Recent DVT, undergoing major surgery– Pregnancy with proximal DVT, undergoing

catheter directed therapy

PROPHYLACTIC APPLICATIONSOF IVC FILTERS

The treatment of extensive iliofemoral deep venous thrombosis with thrombolytic therapy or surgical thrombectomy can cause pulmonary embolism during the procedure. Although permanent vena cava filters

have been used in this setting, retrieval of the filter after resolution of the deep vein thrombosis is appealing.

Patients with Neurological Problems resulting in prolonged immobilization, paralysis, stroke with DVT.

Patients with advanced malignancy and chemotherapy

• Patients with suspected hypercoagulable state

• Case reports in the literature cite success in the use of retrievable vena cava filters for pregnant patients with thromboembolism

• Retrievable vena cava filters “off label” as temporary filters during resection of renal cell cancers

• with tumor thrombus extension into the inferior vena cava.

.

Patent Foramen Ovale

Recognized as a major contributor to morbidity and mortality

Combined procedures of IVC filter and PFO closure may become more frequent

FUTURE APPLICATIONSOF IVC FILTERS

RHEOLYTIC THROMBECTOMY

CATHETER

RHEOLYTIC THROMBECTOMY

CATHETER

PERCUTANEOUS RHEOLYTIC THROMBECTOMY

• Koning et al. (Circulation 1997) - Successful thrombectomy in 2 patients with severe symptomatic pulmonary embolism and contraindications to thrombolytics.

• Voigtlander et al. (Cath Card Interv 1999) - Successful thrombectomy in 3/5 patients with massive pulmonary embolism and contraindications to thrombolytics.

PERCUTANEOUS THROMBECTOMY

• PATIENT 1– 72 Y/O MAN WITH TIA. +DYSPNEA/ +NEAR-

SYNCOPE– TEE : THROMBUS IN RIGHT INFERIOR PA– PULMONARY ANGIOGRAM CONFIRMED– CT SCAN BRAIN: HEMORRHAGIC INFARCT– PERCUTANEOUS THROMBECTOMY WITH

EXCELLENT IMMEDIATE RESULT– DISCHARGED. 1 MO F/U FREE OF THROMBUS

Koning,R et al.Circulation 1997;96:2498-500

PERCUTANEOUS THROMBECTOMY

• PATIENT 2– 74 Y/O MAN, TRAUMA, FX TIBIA– HD 9: RIGHT SIDE CHEST PAIN AND SEVERE

DYSPNEA– P.E., ECG, CXR SUGGESTIVE OF PE– PULMONARY ANGIOGRAM: MASSIVE BILATERAL

EMBOLISM– PERCUTANEOUS THROMBECTOMY TO LLL – DISCHARGED. 1 MO F/U NO THROMBUS LLL.

Koning,R et al.Circulation 1997;96:2498-500

PATIENT CHARACTERISTICS

PATIENT AGE GENDER CLINICAL STATUS CONTRAINDICATION

1 25 M ORTHOPNEA, LOW BP SKULL INJURY

2 70 M CARDIOGENIC SHOCK RECENT SURGERY

3 72 M CARDIOGENIC SHOCK CRITICAL BLEEDING

4 72 M ORTHOPNEA, LOW BP ACTIVE ULCER

5 52 F CARDIOGENIC SHOCK SURGERY 14 D AGO

Voigtlander et al. Cath Card Interv. 47:91-96 1999

CLINICAL RESULTS

• Patients 1,2,3 successfully treated; Pt 2 died on day 12 of cerebral hemorrhage

• Patients 4,5 underwent surgical thrombectomy• 3-month follow-up (Pts 1,3,4,5): normalized RV function

and asymptomatic• Patients 4,5 histological analysis revealed organized thrombi

with partial fibrosis

Voigtlander et al. Cath Card Interv. 47:91-96 1999

ANGIOGRAPHIC RESULTS

PATIENT BEFORE AFTER BEFORE AFTER BEFORE AFTER1 30 24 16 15 11 72 27 23 16 15 11 73 29 26 16 16 11 74 28 27 15 15 13 125 30 30 16 16 14 14

TOTAL MILLER SCORE INVOLVEMENT REDUCTION OF FLOW

(X/34) (X/16) (X/18)

Voigtlander et al. Cath Card Interv.47:91-96 1999

HEMODYNAMIC RESULTS

PRE POST S/P 24H

SYS PAP(mmHG)

60 57 38

Mean PAP(mmHG)

Mean RAP(mmHG)

Artery O2SAT

34

12

84

35

10

90

26

9

98

Voigtlander et al. Cath Card Interv.47:91-96 1999

THROMBECTOMY LIMITATIONS

• RISK OF MECHANICAL PERFORATION ?

• AGE OF THROMBUS– Rate of thrombolysis depends on the age of thrombus

ORGANIZED THROMBUS LYSIS RATE 5 MG/ SEC

NONORGANIZED THROMBUS LYSIS RATE 70 MG/ SEC

Stahr P et al. Z Kardiol 1997: 86 (suppl 2): 289

ANEMIA

EMERGENT SURGICAL EMBOLECTOMY

• Operative mortality rate 30-40%

• Independent predictors of mortality : Cardiac arrest & assoc. cardiopulmonary disease

• Major causes of mortality: incomplete thrombus removal with persistent RV dysfunction, and severe reperfusion lung injury

• Consider as primary therapy in PE > 14 days old

Recent series 29 patients treated by a dedicated team

24 hour availabilityEmergency transport

Surgical technique without aortic crossclamp or cardioplegia

IVC Filters in all patients

Moderate/severe RV dysfunction with extensive PENo antecedent CPR

11% 1-month mortality (89% survival; 26/29 patients)Aklog, Circulation 2002

EMERGENT SURGICAL EMBOLECTOMY

THROMBOENDARTERECTOMY HEMODYNAMIC VALUES

Mean PAP(mm Hg)

49 27 24

Cardiac Output(liters/min)

3.8 5.9 4.9

Pulmonaryvascularresistance

997 230 272

PREOP POSTOP 3 moFOLLOW-UP

Moser et al. Circulation 81: 1735,1990

PREVENTION

• In medical ICU, DVT develops in one third of patients; half of these involved the proximal portion of the leg.

• Choose most adequate prophylactic method

• Keep high index of suspicion, especially in high-risk patients

Hirsch et al. JAMA 1995;274:335-7

SUMMARY

• Pulmonary embolism manifests in spectral fashion, and management (diagnostic and therapeutic) may be just as varied and nonuniform due to options available.

SUMMARY

• Echocardiography is a useful tool for risk-stratification of “stable” patients who otherwise might benefit from a more aggressive approach.

• Echocardiographic evidence of RV Dysfunction adds weight to a clinical suspicion of PE in an unstable patient unable to undergo further testing, therefore, expedites therapeutics.

SUMMARY

• The optimum application of thrombolytic therapy remains in doubt. Some authorities argue for treatment of only unstable patients, while others would enlarge indications to include those with echo or CT evidence of RV Dysfunction.

SUMMARY

• A catheter-based approach seems feasible and safe as primary therapy for massive pulmonary embolism in acute cases (< 14 days old) when thrombolysis is contraindicated or unsuccessful.

• Surgical embolectomy may be a better option for older clots (> 14 days old).

SUMMARY

• Further studies are needed to answer the questions regarding effectivenes and clinical benefit of the catheter-based approach and emergency thrombectomy compared to thrombolytics.

Protocol for the Treatment of Massive Pulmonary Embolism in Patients Who

Have Contraindications to Thrombolytic Therapy using the Possis AngioJet System

Inclusion / Exclusion Criteria

Inclusion • Symptomatic massive PE

• RV Dysfunction

• Contraindications to thrombolysis

• Recent PE < 14 days

• Age > 18

Exclusion• Severe Anemia

• Inability to tolerate hemolysis

• Chronic terminal illness

• PE > 14 days

• Inability to obtain informed consent or follow up

Procedure

• Establish Diagnosis

• Diagnostic Studies– VQ Lung Scan

– Spiral CT

• Echocardiogram for RV Function• Pulmonary Angiography• Rheolytic Thrombectomy• Follow Up 24 hours, at hospital D/C and 30 days

Protocol for the Treatment of Patients with Normotensive Submassive Pulmonary Embolism

with Right Ventricular Dysfunction

• Randomize Patients• Standard Care (anticoagulation) vs. Lytic Therapy• Subgroup patients with contraindications or high

risk for bleeding with thrombolytics can be treated with AngioJet

• Exclude patients with chronic terminal illness• Follow Up Assessment

– Cardiopulmonary Treadmill Testing– VQ Lung Scan

Protocol for the Treatment of Patients with Normotensive Submassive Pulmonary Embolism with Right Ventricular Dysfunction:Follow-up

Assessment and End-points

30 day mortality

Bleeding complications

Thrombolytic dose and cost

Echo

V/Q lung scan

Cardiopulmonary Stress test

Contemporary Management of Pulmonary Embolism

Lowell I. Gerber M.D.