Difference in Guidelines
ACEP – not enough data for full-dose lytics for submassive PE
AHA – reasonable to consider it; however, there’s been some new studies since AHA guidelines
ESC, ACCP – recommend against lytics in submassive PE -> recommend rescue lysis if pt progresses to massive
Need to identify who will progress to decompensation
Risk Scores
- PESI/sPESI/msPESI
- Does not require a lot of labs
- Identifies whom you can send home -> good way to find peeps you can send home with AC
- From the ICU, you need a test with specificity -> need to identify who is going to die
- ESC 2014 Guidelines -> how to generally risk stratify
- If you only have either one of lab or imaging evidence of RV strain = IM-low risk
- But, if you have more than of lab or imaging evidence of RV strain = IM-high riks
- Was not validated
- BOVA score -> identifies step-wise increase in short-term risk
- Systolic hypotension
- Troponinemia
- RV dysfunction on imaging
- Increased HR
Catheter-Directed Lysis
ULTIMA 2014 – RCT of 59 pts <- the only RCT on catheter-directed lysis
- Submassive via RV:LV ratio on TTE echo
- Primary outcome – improvement in RV:LV ratio in 24 hours
- Statistically significant result
- However, when you followed up at 90 days, there was no difference in RV:LV ratio
- Questionable part of this trial was that there was zero death and zero hemodynamic decompensation at 90 days
- *The only RCT for catheter-directed lysis*
- Seems that most of the data shows that catheter-directed lysis is safe
- Efficacy data is questionable
Half-Dose Lysis
MOPETT 2013 Sharifi – diagnosed intermediate risk via CT and counting number of lobes involved
- 50 mg with 10 mg bolus then the rest over remaining 2 hours
- Primary outcome was echo PASP over 40 mm Hg and/or recurrent PE
- Found sig better PA pressures both at 48 hours and when followed up at 2 years
Commentary: Not sure what to do with echo-findings of R sided pressures
- Also, until you have a right heart cath, it’s weird to call someone pulmonary HTN
- Did have mortality similar to other registries
- Odd that half-dose isn’t mentioned as much as catheter-directed lysis; only mentioned in the ESC Guidelines…not the others
Conclusions
- Currently, if you give routine lytics in submassive PE, you are going against current guidelines
- The trick is going to be identifying a higher risk subgroup of submassive PE <- i.e. calculating a BOVA score. This may tip the risk-benefit balance in favor of lytics.
- Lower risk therapies like catether-directed lysis or half-dose lytics may also tip the risk-benefit balance in favor of the intervention.
CRITICAL CARE BY CLARK 