Early death (within 7-30 days) in PE patients is concerning. It is relatively easy to identify high-risk PE patients, defined by abnormal vitals SBP < 90 or drop in SBP by 40 for at least 5 min.
Normotensive patients with poor prognostic indicators include (statistically significant odds ratios):
- SBP between 90-100 (OR 2.45)
- HR > 110 (OR 1.87)
- elevated cardiac enzymes (OR 2.49)
- RV dysfunction (abnormal RV function on echo or RV dilation on echo or CT) (2.28)
Patients who have biomarkers for heart strain and RV dysfunction may benefit from some form of interventional therapy:
- lower (half) dose fibrinolytic therapy for patients < 75 years of age
- local, catheter-delivered, ultrasound-assisted thrombolysis
Other things to note:
- intubation increases intrathoracic pressure, which may decrease venous return and further worsen R sided dysfunction
- extracorporeal membrane oxygenation can help temporize heart and lung collapse where available but is not definitive management
- heparin is still mainline therapy for normotensive patients with PE but without any indications of RV dysfunction or no elevated biomarkers
Sanchez O, Planquette B, Meyer G. Management of massive and submassive pulmonary embolism: focus on recent randomized trials. Curr Opin Pulm Med. 2014 Jul 15.