Pulmonary embolism: update on management and controversies

Abstract

Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. The diagnosis, risk assessment, and management of pulmonary embolism have evolved with a better understanding of efficient use of diagnostic and therapeutic options. The use of either clinical probability adjusted or age adjusted D-dimer interpretation has led to a reduction in diagnostic imaging to exclude pulmonary embolism. Direct oral anticoagulation therapies are safe, effective, and convenient treatments for most patients with acute venous thromboembolism, with a lower risk of bleeding than vitamin K antagonists. These oral therapeutic options have opened up opportunities for safe outpatient management of pulmonary embolism in selected patients. Recent clinical trials exploring the use of systemic thrombolysis in intermediate to high risk pulmonary embolism suggest that this therapy should be reserved for patients with evidence of hemodynamic compromise. The role of low dose systemic or catheter directed thrombolysis in other patient subgroups is uncertain. After a diagnosis of pulmonary embolism, all patients should be assessed for risk of recurrent venous thromboembolism to guide duration of anticoagulation. Patients with a venous thromboembolism associated with a strong, transient, provoking risk factor can safely discontinue anticoagulation after three months of treatment. Patients with an ongoing strong risk factor, such as cancer, or unprovoked events are at increased risk of recurrent events and should be considered for extended treatment. The use of a risk prediction score can help to identify patients with unprovoked venous thromboembolism who can benefit from extended duration therapy. Despite major advances in the management of pulmonary embolism, up to half of patients report chronic functional limitations. Such patients should be screened for chronic thromboembolic pulmonary hypertension, but only a small proportion will have this as the explanation of their symptoms. In the remaining patients, future studies are needed to understand the pathophysiology and explore interventions to improve quality of life.

Clinical significance for combined coagulation indexes in epithelial ovarian cancer prognosis

“…Moreover, an activated coagulation state in tumor tissues could form a fibrin matrix to shield tumor cells against the immune attack and foster tumor growth, which finally contributes to poor cancer prognosis [ 27 , 28 ]. Previous studies indicated that D-dimer, a degradation product produced by hydrolysis of fibrinolytic protein, could assess secondary fibrinolytic activity and hyper-coagulability [ 29 ]. Meanwhile, the INR system, applied to standardize PT, could evaluate the “extrinsic coagulation pathway” in individuals [ 30 ].…”

Surgical Treatment in a High-Risk Pulmonary Embolism: Case Report

“…The types of treatment in acute pulmonary embolism vary with the clinical presentation. Anticoagulation and thrombolysis are the standard means of treatment for acute pulmonary embolism, but these are to be reserved for hemodynamically stable patients [ 18 ]. Clinical data suggest that patients being treated by thrombolysis are at a higher risk of death by increased risk of major hemorrhage and a high probability of pulmonary embolism recurrence compared with patients treated by pulmonary embolectomy [ 19 , 20 ].…”

Anticoagulation in COVID-19: current concepts and controversies

“…Models such as the Pulmonary Embolism Severity Index (PESI) and the simplified-PESI (sPESI) risk prediction scores provide a tool for identification of low-risk and high-risk patients. 22 According to ESC guidelines, treatment of high-risk acute PE includes early oxygenation in the form of ventilation if required, ensuring haemodynamic stability, and management of right heart failure, including need for vasopressors and advanced life support in severe cases. 23 The CHEST guidelines provide specific recommendations regarding choice of anticoagulant with respect to phase of VTE treatment.…”