Morning Report: Management if Submassive PE

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Management of Submassive (Intermediate Risk) PE

Massive PE (high risk): acute PE causing hemodynamic instability and hypotension, pulselessness, or profound bradycardia

Submassive PE (intermediate risk): hemodynamically stable PE w/ right ventricular dysfunction (RVD) or myocardial necrosis.

Low risk PE: lacks RVD or hypotension.

RV DysfunctionPresence of at least 1 of the following:

— RV dilation (apical 4-chamber RV diameter divided by LV diameter >0.9) or RV systolic dysfunction on echocardiography — RV dilation (4-chamber RV diameter divided by LV diameter >0.9) on CT

— Elevation of BNP (>90 pg/mL)
— Elevation of N-terminal pro-BNP (>500 pg/mL); or

— Electrocardiographic changes (new complete or incomplete right bundle-branch block, anteroseptal ST elevation or depression, or anteroseptal T-wave inversion)

PEITHO

Effectiveness of full dose tenecteplase with heparin(TG) compared to heparin(CG) in patients with intermediate-risk pulmonary embolus.
TG had less hemodynamic compromise, but higher risk of hemorrhage and stroke.

MOPETT trial

Role of half-dose alteplase with heparin in reduction of pulmonary artery pressure in moderate risk PE.
Thrombolytic (ateplase +anticoagulation) group had less pulmonary hypertension, recurrent PE and death when compared to control (anticoagulation alone).
Bleeding did not occur in the treatment or control group.
The results of the study suggest that half-doses alteplase is safe and effective in moderate PE with reduction in pulmonary hypertension.

Meta-analysis (Chaterjee et al.)

Compared thrombolysis to anticoagulant therapy in patients with intermediate risk PE.
Outcomes: all-cause mortality and bleeding risk.
Thrombolytics were associated with overall lower all-cause mortality, lower rate of recurrent PE, and greater risk of major bleeding.
However, major bleeding was not seen in patients 65 and younger

References:

Sharifi M, Bay C, Skrocki L, et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” Trial). Am J Cardiol. 2013;111(2):273-277
Chatterjee S, Chakraborty A, Weinberg I, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014;311(23):2414-2421.
Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for Patients with Intermediate-Risk Pulmonary Embolism. New England Journal of Medicine. 2014;370(15):1402-1411