Management of Acute Pulmonary Embolism With a Pulmonary Embolism Response Team

Jason R. Cuomo, MD; Vishal Arora, MD; Thad Wilkins, MD

Disclosures

J Am Board Fam Med. 2021;34(2):402-408. 

In This Article

Abstract and Introduction

Abstract

Despite recent advances in the assessment, risk stratification, and treatment of acute pulmonary embolism (PE), it remains a leading cause of cardiovascular morbidity and mortality in the United States each year. Patient presentation and prognosis are heterogeneous, and a variety of diagnostic and therapeutic instruments have arisen to assist in providing patients with the appropriate level of care and aggressiveness of approach. Fortunately, a growing number of institutions now have pulmonary embolism response teams (PERT) that urgently assist with risk assessment and management of patients with massive and sub-massive PE. In service of providers at the point of contact with acute PE, this review aims to summarize the data pertinent to rapid risk assessment and the interpretation of diagnostics used to that end. The role of PERT and the indications for systemic fibrinolysis and invasive therapies are also discussed.

Introduction

Despite recent advances in the assessment, risk stratification, and treatment of acute pulmonary embolism (PE), it remains a leading cause of cardiovascular morbidity and mortality, resulting in over 350 000 hospitalizations and over 100 000 deaths in the United States each year.[1,2] The indirect costs of PE and venous thromboembolic events are also considerable, both concerning increased rates of long-term disability and decreased quality of life.[3] The distribution of these insults among patients with PE is heterogenous in the extreme. Treatment options include outpatient management with oral anticoagulation, administration of high-risk fibrinolytic therapy, catheter-directed thrombolysis, or cardiothoracic surgery.[4] Finally, as our understanding of acute PE and its chronic sequelae has deepened, a carefully selected intermediate-risk group of patients has been identified who experience morbidity and mortality benefits following targeted invasive therapies.[5–7]

It follows that clinical decision-making in acute PE is complex, and the presence of systemic fibrinolytics in the decision-tree guarantees that the stakes are high. Fortunately, PE has remained an area of active research in recent years, and a variety of tools are now available to assist providers on the front lines in accurately distinguishing between these presentations. The proliferation of pulmonary embolism response teams (PERT) at tertiary centers throughout the United States provides a rapid subspecialty response in intermediate- and high-risk cases.[8] The present article aims to examine the following recommendations: (a) furnish providers at the point of contact with acute PE with the means to perform an accurate risk assessment, (b) review the data directing the use of systemic fibrinolysis in high-risk patients, and (c) provide an overview of the PERT process, with emphasis on how patients are selected for advanced therapies, highlighting the crucial role of providers at the point-of-contact in re-stratifying patients as "intermediate-low" and "intermediate-high" risk.

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