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Risk stratification and treatment strategy of pulmonary embolism

Penaloza, Andreaa; Roy, Pierre-Marieb; Kline, Jeffreyc

Current Opinion in Critical Care: August 2012 - Volume 18 - Issue 4 - p 318–325
doi: 10.1097/MCC.0b013e32835444bc
EMERGENCIES: Edited by Alan E. Jones

Purpose of review: Pulmonary embolism remains one of the leading causes of cardiovascular mortality. The wide range of reported mortality rates reflects heterogeneity in comorbidity and severity of pulmonary embolism. Optimizing risk stratification to prognose pulmonary embolism patients appears to be important to improve management, treatment and clinical outcome.

Recent findings: Hemodynamic status is the most important short-term prognostic factor. High-risk pulmonary embolism or massive pulmonary embolism is defined by the patient response more than the clot size: patients with circulatory shock including sustained hypotension should receive thrombolytic therapy in absence of contraindications. Nonmassive or normotensive pulmonary embolism can be further stratified using clinical features, imaging (echocardiography, computed tomography) and biomarkers (troponins, natriuretic peptides): low-risk pulmonary embolism, evaluated by clinical model (Pulmonary Embolism Severity Index; PESI) can potentially be treated as outpatients; and intermediate-risk pulmonary embolism, which can be further stratified into less-severe and more-severe intermediate risk. The last may benefit from intensive clinical surveillance but the risk–benefit ratio for thrombolysis has been inadequately quantified to make any strong recommendation. New anticoagulants may transform traditional pulmonary embolism treatment.

Summary: Optimizing risk stratification of patients with normotensive pulmonary embolism before they develop overt hemodynamic instability is the challenge of current pulmonary embolism management. Treatment strategy has to integrate this risk stratification and new anticoagulants arrival.

aEmergency Department, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium

bEmergency Department, LUNAM Université, Angers, Université d’Angers, CHU Angers, France

cDepartment of Emergency Medicine, Carolinas Medical Center, Charlotte, USA

Correspondence to Andrea Penaloza, MD, Emergency Department, Cliniques Universitaires St-Luc, Université Catholique de Louvain, 10, av. Hippocrate, 1200 Brussels, Belgium. Tel: +32 2 764 16 13; e-mail: andrea.penaloza@uclouvain.be

© 2012 Lippincott Williams & Wilkins, Inc.