When anticoagulation is not enough for PE

This topic is discussed in the January 2009 issue of the American Journal of Emergency Medicine.

There is no controversy about the fact that patients with acute PE who are hemodynamically stable need anticoagulation with heparin (or low molecular weight heparin) and not thrombolytic therapy. For patients who present with hypotension (massive PE) the consensus (although not without some controversy) favors thrombolytic therapy.

Two other situations present more difficulty in decision making: the patient with evidence of right ventricular dysfunction who is hemodynamically stable and the patient with suspected massive PE presenting in cardiac arrest. These two situations are the focus of the paper which, although not a systematic review, is the best evidence synthesis I’ve seen on the topic so far.

Points of interest:

The responsibility for hemodynamic stratification and choice of treatment often falls to the emergency room physician.

Apparently hemodynamically stable patients should have cardiac biomarkers performed (troponin and BNP or proBNP).

Those with elevated biomarkers should be evaluated for RV dysfunction via echocardiography.

Patients with echocardiographic evidence of RV dysfunction should be considered for systemic thrombolytic therapy based on careful clinical assessment of multiple factors.

Around half of patients with witnessed arrests whose presenting rhythm is PEA have massive PE. The British Thoracic Society guidelines recommend thrombolytic therapy in such patients, in whom a diagnosis of PE is suspected on clinical grounds. Fears of bleeding related to the trauma of CPR have been unfounded.