Recent Updates and Debates in PE Care - PowerPoint Presentation

Slide1

Recent Updates and Debates in PE Care

David Kirk

1/22/2015

Slide2

i

cubootcamp.com

Slide3

Triage

Massive / Shock -> Thrombolysis

Submassive

No RV

strain -

> Routine Anticoagulation

Slide4

Massive PEs

Need thrombolysis.

Slide5

(CHEST 2002; 121:877–905)

Slide6

“Golden Hour”

“In

fatal cases, it has long been recognized that two

thirds

of those patients will die within 1 h of

presentation

and that anatomically massive PE will only account for one half of those deaths, with the remainder attributed to smaller

submassive

or recurrent emboli

.”

(CHEST 2002; 121:877–905)

Slide7

PE with Shock

Should receive immediate systemic thrombolysis unless contraindications.

Patients with contraindications or treatment failure should have risks/benefits weighed for catheter-directed

tPA

or other salvage therapies.

ACCP guidelines. http://

journal.publications.chestnet.org

/

issue.aspx?journalid

=99&issueid=23443&direction=P

Slide8

Submassive PEs

At risk of needing thrombolysis

Slide9

(CHEST 2002; 121:877–905)

Slide10

Slide11

Systemic

Thrombolysis for Submassive PE

Unlikely (conflicting) mortality

b

enefit

More bleeding including ICH

Less

decompensation

PEITHO - n

engl

j med 370;15

nejm.org

april

10, 2014

Journal of Thrombosis and

Haemostasis

, 10: 751–759

(higher death)

JAMA. 2014;311(23):2414-2421. doi:10.1001/jama.2014.5990

(lower death)

Slide12

Death may decide when doctors disagree

Slide13

Judgment in Submassive PEs

“…thrombolytic

therapy in this

population

should be individualized and benefits and risks (of bleeding) should be carefully weighed on a case-by-case basis

.”

Tapson

.

Uptodate

.

Slide14

Submassive Treatment

Anticoagulation with LMWH

vs

heparin and careful observation is primary treatment.

Decompensation

Thrombolysis should be used as primary rescue.

Catheter-directed therapy should only be considered in patients with contraindications to systemic

lytics

.

ESC PE Guidelines 2014. European Heart Journal (2014) 35, 3033–3080

Slide15

Who Goes to ICU?

Need or high potential need for thrombolysis

Shock

Altered mental status

Severe RV dysfunction

Severe hypoxemia

Other factors to weigh…

Cancer

Increased levels of BNP or troponins

Severity of RV dysfunction

Comorbidities

Slide16

PESI / sPESI

ESC PE Guidelines 2014. European Heart Journal (2014) 35, 3033–3080

Slide17

Low Risk PEs

LMWH over heparin

Routine use of IVC filters is not recommended.

Coumadin with goal INR of 2.5 for at least 3 months.

Most novel anticoagulants for chronic therapy are probably okay.

In patients with cancer consider treatment with LMWH for at least 3-6 months and extended anticoagulation until cancer is cured.

ESC PE Guidelines 2014. European Heart Journal (2014) 35, 3033–3080

Slide18

Outpatient Treatment of PEs

Probably safe to send home from ER or early discharge under the following conditions:

No cancer

No history of chronic lung or cardiac disease

Pulse less than 110

Systolic BP > 100

Saturation > 90%

Reliable outpatient care and access to anticoagulation

ESC PE Guidelines 2014. European Heart Journal (2014) 35, 3033–3080

Slide19

PESI / sPESI

ESC PE Guidelines 2014. European Heart Journal (2014) 35, 3033–3080

Slide20

Current Best Resources

ACCP Antithrombotic Guidelines, 9

th

Edition (2012)

2014 ESC Guidelines on the diagnosis

and management

of acute pulmonary

embolism.

Slide21

Catheter-Directed Thrombolysis

Slide22

Parallels

(http://

digiphotomag.com

/articles/many-traveled-roads-an-interview-with-

harvey

-stein/)

Slide23

Parallels

Catheter-directed treatment of CVAs / DVTs

Cather-directed treatment of PEs

Slide24

“No Better Than IV tPA

”

Slide25

But wait! MR CLEAN

13.5% increase in functional independence without changes in mortality or symptomatic ICH.

More specific therapies and patients:

New stents

P

roximal arterial occlusion

90% failed systemic thrombolysis

N

Engl

J Med 2015;372:11-20. DOI: 10.1056/NEJMoa1411587

Slide26

Too Slow

“The time from symptom onset to endovascular treatment start was too long (1-3 hours) and this delay places [intra-arterial therapy] at a significant disadvantage.”

Barreto

, Endovascular Therapy for Acute Ischemic Stroke -- An Update

Slide27

CVA Parallel

“

We did have one patient

several

years ago who was sent to the

cath

lab and did not receive IV t-PA when she was a candidate

.”

Slide28

DVT Parallel

Catheter-directed treatment of DVT versus anticoagulation

Mortality unchanged

Blood transfusions, PEs, ICH, length of stay, and IVC filter placements all significantly higher

Three times more hospital charges

(http://

archinte.jamanetwork.com

/

article.aspx?articleID

=1889011)

Slide29

ULTIMA

Nonblinded

, industry-involved trial 59 patients (out of 304 screened)

Ultrasound Catheter TPA up to 4hrs

vs

heparin

Required RV/LV ratio > 1.0

Not powered for survival or bleeding

complications.

RV/LV ratio improved faster with intervention

Heparin group “caught up” by 90 days

Slide30

Natural PE Course

“Most

patients with PE treated with anti

-coagulation

alone will achieve embolus resolution at 4 weeks

.”

“The

feared consequence of resultant

chronic thromboembolic

pulmonary

hypertension occurs only

0.1% to 3.8% of patients with

PE”“Mortality after submassive PE is uncommon”

(Circulation. 2014;129:420-421)

Slide31

ULTIMAtely Meh?

Small, not blinded, industry-involved

ULTIMA shows that US facilitated

tPA

compared to heparin rapidly improves RV size.

IVC / RV improvement not significantly different at 90 days.

No survival or bleeding data

Slide32

Seattle-II

Industry-funded, not (yet?) published

US Catheter directed TPA

No comparison group

No ICH.

M

ajor bleeding 11.3%

Many patients required two catheters.

RV/LV

ratio acutely

improved

1 death due to PE (0.5%). 3 total deaths (2%).

http://

www.medscape.com

/

viewarticle

/823571#

Slide33

Seattle Pee

-

eww

?

Industry-funded. Not published.

No comparison group.

Although no ICH reported, major bleeding appears as high

as systemic

t

PA

. 11.3%

vs

11.5%.Apparently only shows short-term RV improvement.

Slide34

Chronic thromboembolic pulmonary

hypertension?

40% never diagnosed with DVT or PE

0.57%

incidence in patient’s with PE

Only 10/170 (5.8%) with symptoms actually have CTEPH

“Because

of the very low incidence of CTEPH after PE, the implementation of extensive follow-up programs for the detection of CTEPH after acute PE seems to be unnecessary

.”

Haematologica

. Jun 2010; 95(6): 970–975.

Slide35

Chronic RV Dysfunction?

159 heparin

vs

19 TPA

Neither 6 minute walks nor NYHA scores were significantly different between heparin and thrombolysis.

RV

hypokinesis

no difference between the two groups (7%

vs

6%)

Subgroup analysis showed that in heparin only group 27% had “increase in RVSP” and 46% had symptoms. However, more

tPA

patients had RVSP > 40 (11%

vs

7%).

(Chest / 136 / 5 / November, 2009)

Slide36

ACCP Guidelines

“In

patients with acute PE when a thrombolytic agent is used, we suggest administration through a peripheral vein over a pulmonary artery

catheter.”

“In

patients with acute PE associated with hypotension and who have (

i

) contraindications to thrombolysis, (ii) failed thrombolysis, or (iii) shock that is likely to cause death before systemic thrombolysis can take effect (

eg

, within hours), if appropriate expertise and resources are available, we suggest catheter-assisted thrombus removal over no such

intervention.”

“In

patients with acute PE who are treated with anticoagulants, we recommend against the use of an IVC

filter.”

http://

journal.publications.chestnet.org

/

issue.aspx?journalid

=99&issueid=23443&direction=P

Slide37

Conclusions

Our history with CVAs should be a lesson to us. Despite initial promising studies, most trials of catheter-directed therapy have shown no benefit over standard of care.

Slide38

Conclusions

Although catheter directed thrombolysis for

submassive

PEs may show some promise, these early industry-supported studies have shown no meaningful long term improvement over routine care.

Catheter-directed thrombolysis should remain an option in patients who have contraindications or fail systemic therapy.