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.

 

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