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Dr. Nicolas Meneveau,
The aim of this symposium was to understand the latest clinical developments in acute pulmonary embolism (PE) management, where the ESC guidelines previously lacked evidence. This session focused mainly on the various tools available for risk stratification of acute PE. The simplified PESI score (sPESI), based on clinical variables only (age >80 years, cancer, cardiopulmonary disease, heart rate >110 min, systolic blood pressure (SBP)<100 mmHg, oxygen saturation <90%), showed excellent sensitivity and negative predictive value (NPV) (approaching 100%). This score therefore appears ideal for application in low risk PE patients (PE-related early death ≤1%), and could thus help to identify patients who could be treated as outpatients. There remains debate about the use of imaging tests (echocardiography, CT) and laboratory markers (cardiac troponin, natriuretic peptides), which are used to identify intermediate-risk PE (PE-related early death between 3 and 15%). The distinction between low and intermediate risk is important for prognosis and therapeutic decision-making. It is debatable whether echo or CT “alone” can identify intermediate risk PE among normotensive patients. Neither imaging method has been shown to identify candidates for “advanced” treatment in the absence of haemodynamic instability (a criterion that defines high-risk PE), although CT has been shown to yield better performance than echocardiography alone, whose NPV is very low. The same can be said for the prognostic value of biomarkers. Troponin levels did not adequately distinguish between high and low risk PE. In addition, these are non specific tests, with a low positive predictive value (PPV), and there is no appropriate cut-off value for BNP and NT-pro-BNP. The combination of imaging plus biomarkers makes it possible to identify intermediate PE patients who are at higher risk of complications (15% of all PE patients; odds ratio 10 [2.14-47]). PEITHO, a large, randomized European trial, will soon determine whether definition of intermediate risk PE by imaging plus biomarkers will have implications for acute management, i.e. the indication for early thrombolysis in this population. Future risk stratification scores and strategies may need to include more data (comorbidity) and define a smaller proportion of patients most likely to benefit from “advanced” early treatment (i.e. thrombolysis or intervention). New developments in PE treatment are primarily related to the development of new oral anticoagulants (NOACs). In the RECOVER studies, dabigatran was non-inferior to well-controlled warfarin for the acute treatment of symptomatic venous thrombo-embolism (VTE) (approx. 30% PE), following initial parenteral anticoagulant treatment. Lower rates of major or any bleeding events were observed with dabigatran vs warfarin. The REMEDY and RESONATE studies evaluated the long-term administration of dabigatran vs warfarin (REMEDY) or vs placebo (RESONATE). Dabigatran was shown to be non-inferior to warfarin in terms of thrombo-embolic events, with a significant reduction in bleeding complications. However, this was achieved at the price of an increased risk of acute coronary syndrome. Compared to placebo, dabigatran is associated with a relative risk reduction of 92% in thrombo-embolic events, albeit at the cost of a small increase in bleeding risk. Finally, the EINSTEIN DVT and EINSTEIN PE studies showed that oral rivaroxaban (15 mg twice daily for 3 weeks, followed by 20 mg once daily) provides patients and clinicians with a simple, single-drug approach for the acute and continued treatment of both DVT and PE with a potential improvement in risk-benefit profile. Lastly, ultrasound-assisted thrombolysis is currently being evaluated in the treatment of intermediate-risk PE. Results of two studies (one randomized European study and one observation US study) should provide additional insights into the useful of this approach.
What is new in acute pulmonary embolism?