Current Guidelines for the Management of Pulmonary Embolism

Current Guidelines for the Management of Pulmonary Embolism Michael R. Jaff, D. O. , F. A. C. C. Professor of Medicine Harvard Medical School Boston, Massachusetts

Michael R. Jaff, D. O. Disclosure • Consultant – Abbott Vascular (non-compensated) – AOPA – Boston Scientific (non-compensated) – Cordis Corporation (non-compensated) – Medtronic (non-compensated) – Micell, Inc – Primacea – Vactronix – Venarum – Volcano/Philips Equity – Embolitech – Janacare, Inc – MC 10 – Northwind Medical, Inc. – PQ Bypass, Inc – Primacea – Sano V, Inc. – Vascular Therapies, Inc • Board of Directors – Greenway Health March 2018 3 3 •

What Modern Guidelines Exist? 2011 2016

Before the ESC 2014 Guidelines, PE were Categorized as: MASSIVE Shock / Hypotension SUBMASSIVE Normotensive + RV Strain LOW RISK None of the above

However Intermediate Risk is Heterogeneous Becattini C, Agnelli G. Predictors of mortality from pulmonary embolism and their influence on clinical management. Thromb Haemost. 2008; 100(5): 747– 751 Abrahams van-Doorn P. and Hartmann IJC. Imaging Insights. 2011; 2: 705 -715 Dalen JE. Chest. 2002; 122: 1801 -17

ESC 2014 Guidelines: PE Categories Eur Heart J. 2014 Nov 14; 35(43): 3033 -69

Thrombolysis in PE: Multiple Positive Physiological Effects • • Improved early clot resolution Reduced pulmonary arterial pressure Improved lung perfusion Improved early angiographic flow PIOPED Investigators. Chest. 1990; 97: 528 -33 Levine M. et al. Chest. 1990; 98(6): 1473 -9 Dalla-Volta S. et al. JACC. 1992. 20(3): 520 -6 Goldhaber SZ. et al. Lancet. 1993; 341(8844): 517 -11 Jaff MR. et al. Circulation. 2011; 123: 1788 -1830 Daniels LB. AJC. 1997; 80: 184 -8

There is One Obvious Downside…

The Higher the PE-Related Risk, the Easier the Decision to Administer Lytics

Thrombolysis Performed Better Than Anticoagulation for Massive PE Jerjez-Sanchez C. et al. J Thrombolysis. 1995; 2(3): 227 -8

ESC Treatment Guidelines – High Risk PE Eur Heart J. 2014 Nov 14; 35(43): 3033 -69

What About Submassive PE Patients Who Represent Lower PERelated Risk?

AHA PE Treatment Guidelines 1 2 “…potential” 3 “…IV” Jaff MR. et al. Circulation. 2011; 123: 1788 -1830

PEITHO: Advantage driven by reduced hemodynamic collapse No mortality advantage Less treatment escalation N Engl J Med 2014; 370: 1402 -11

More bleeding with thrombolysis N Engl J Med 2014; 370: 1402 -11

ULTIMA: Design • Randomized, Controlled • Ultrasound-Assisted Catheter-Directed Thrombolysis • Acute Intermediate-Risk PE Circulation. 2014 Jan 28; 129(4): 479 -86

ULTIMA: Quicker Resolution of RV Dysfunction: Indirect Evidence of Efficacy Circulation. 2014 Jan 28; 129(4): 479 -86

ULTIMA: Complications • No major bleeding • 4 minor bleeding: – 3 patients in the USAT group (10%): Transient hemoptysis, access site groin hematoma – 1 patient in the heparin group (3%): Muscular hematoma Circulation. 2014 Jan 28; 129(4): 479 -86

Meta-Analysis: Mortality Benefit for Lytics in Sub-Massive PE JAMA. 2014 Jun 18; 311(23): 2414 -21

Absolute risk / benefit analysis: Know the #’s JAMA. 2014 Jun 18; 311(23): 2414 -21

Making Sense of PE Treatment in the Real World

PE are Diagnosed More; Outcomes are Better Konstantinides et al. JACC. 67(8): 976 -990

ECMO Reduces Mortality in the Sickest of PE Patients Other aggressive therapies were made possible Thirty-day survival increased from 17. 2% 41. 4% era (p=0. 043) Vasc Med 2018; 23: 60 -4

When to Use Suction Thrombectomy is Not Clear Catheter Cardiovasc Interv. 2015 Aug; 86(2): E 81 -7

High-risk is straightforward Intermediaterisk Perhaps only rescue? Low-risk is straightforward Konstantinides et al. JACC. 2016; 67(8): 976 -990

Take Home Messages • Understand appropriate risk stratification for PE patients • Treating low and high risk PE is straightforward • Treating intermediate risk PE is NOT straightforward

Many Think PERT is the Answer! Giri JS, Piazzi G. Vasc Med 2018; 23: 72 -4.