what can we do for “intermediate risk” pulmonary embolism · sub-massive pe “intermediate...
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What Can We Do For “Intermediate Risk”
Pulmonary EmbolismDr Alex West
Respiratory ConsultantGuy’s and St Thomas’ Hospital
London
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Declarations - none
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Definitions of PE – “size”
Formally know as…- massive
- sub-massive- non-massive
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Definitions of PE – “size”
Now know as…- High Risk
- Intermediate Risk- Low Risk
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“Risk”….. Mortality
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Massive PE“High Risk PE”
• SBP < 90 mmHg or drop of >40 mmHg• >15 mins • with no other cause• Up to 5-10% of patients• Mortality – high (15-58%)
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High Risk PE - Treatment
• Resuscitation• “Full Dose” systemic thrombolysis• tPA – 10mg bolus, 90mg / 2 hours
• Risk of major bleeding (6-20%)• Intracranial Haemorrhage (2-6%) • ….But outweighs risk of death from PE
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Sub-massive PE“Intermediate Risk PE”
• Not hypotensive but…• Evidence of right heart dysfunction
(CT or ECHO)• Evidence of myocardial injury/strain
– elevated biomarkers - Troponin & BNP• Confirmed large clot burden – CTPA (V:Q)
• Mortality or “Adverse Events” 3-25%?
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So why not thrombolyse“intermediate risk PE” too?
Much “pro/con” debate on going….
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“Adverse Events” from Intermediate Risk PE(This group can be very well!)
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American Guidelines – Chest 2016
• Intermediate risk PE
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*23. In selected patients with acute PE who deteriorateafter starting anticoagulant therapy but haveyet to develop hypotension and who have a lowbleeding risk, we suggest systemically administeredthrombolytic therapy over no such therapy(Grade 2C).
American Guidelines – Chest 2016
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*23. In selected patients with acute PE who deteriorateafter starting anticoagulant therapy but haveyet to develop hypotension and who have a lowbleeding risk, we suggest systemically administeredthrombolytic therapy over no such therapy(Grade 2C).
….Dose not suggested
American Guidelines – Chest 2016
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MOPETT Trial
• Concept of “Safe Dose Thrombolysis”?• Cardiac output – Brain 15%, Heart 5%, Pulmonary 100%
• tPA - 10mg bolus• tPA - 40mg/2 hours (0.5mg/kg if <50kg)
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MOPETT Trail
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MOPETT Trail
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“PERT”
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A Pragmatic British Alternative…
And applicable to DGH as teaching hospitals alike…
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PE Lysis Team- “PELT”
• Chest Physicians• Critical Care• Haematologists• Interventional Radiology• (Obstetric Physician)
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PE Lysis Team- “PELT”
• Chest Physicians• Critical Care• Haematologists• Interventional Radiology (pt bleeding risk)• (Obstetric Physician)
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Intermediate Risk PE
• Not shocked but…• Evidence of right heart dysfunction• Evidence of myocardial injury
– elevated Troponin , BNP• Confirmed large clot burden – CTPA (V:Q)
• Mortality or “Adverse Events” 3-15%?
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Intermediate Risk PE
• Not shocked but…• Evidence of right heart dysfunction*• Evidence of myocardial injury
– elevated Troponin*, BNP*• Confirmed large clot burden* - CTPA (V:Q)
• Mortality or “Adverse Events” 3-15%....• Predictors* – both +ve and -ve
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European Guidelines - 2014
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PE Lysis Team- “PELT”
• Initial Clinical Assessment• ECHO• Bilateral leg Dopplers • Bleeding risk (NB age, Pulmonary infarction)
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PE Lysis Team- “PELT”
• Initial Clinical Assessment• ECHO• Bilateral leg Dopplers • Bleeding risk (NB age, Pulmonary infarction)
• Serial Assessment – review progress• Patient involvement in decisions/consent • …..then you make a TEAM judgement
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Key “Take Home” Message
Is your patient…
Intermediate-High Risk (?Lysis)Or
Intermediate-Low Risk (Lysis unlikely)
(but can change groups with time and treatment)
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Local Protocol for Intermediate Risk PE
• Team decision• Done in level 2 or 3• Systemic “half dose” first line• Catheter direct Thrombolysis for
- bleeding risk (eg post surgery)- Second line (post systemic, including massive PE)- “Older Clot”?
• (Local outcome very good… thus far)
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Catheter Directed Thrombolysis
• Interventional Radiology• Time is situ 12-24 hours• Infuse tPA 0.5-1mg per hour• Lower total dose• Mostly bilateral (and each side “adjusted”)
• Still risk of bleeding and arrhythmia
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EKOS™ Endovascular SystemFeatures
―――
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Acoustic Pulse Thrombolysis™ treatmentMechanism of action
Fibrin SeparationUltrasound separates fibrin
without fragmentation of emboli
Active Drug Delivery Drug is actively driven into clot by
“Acoustic Streaming”
EKOS™ Acoustic Pulse Thrombolysis™ treatment is a minimally invasive system for accelerating thrombus dissolution.
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Summary
• Ongoing clinical assessment in “place of safety”
• Intermediate-high or intermediate-low risk• Advances in TEAM decisions for the more
severe PEs to enable improved morbidity and mortality