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Acute pulmonary embolism - 2010

ESC Congress 2010

Valvular, Myocardial, Pericardial, Pulmonary, Congenital Heart Disease
Venous Thromboembolism

This session focused on three main points. Firstly, a recap of the state of art on the basis of available registry data, in particular the RIETE and ZATPOL registries.

Adam Torbicki reported results from the ZATPOL registry, a Polish registry with 170 participating Cardiological Departments. The objective of ZATPOL was interactive internet-based education. Quality of management of pulmonary embolism (PE) was evaluated at baseline, and recommendations were recalled through participation in the online registry. Then, quality of care was evaluated again three months later, to identify whether participation in the registry had improved practices. In total, just over 2000 patients were included. Among 20% of these, PE confirmation or exclusion was not based on validated criteria. The prevalence of PE was 35% among patients in whom the diagnosis of PE had been excluded, although the diagnostic strategy had adhered to the most straightforward ESC algorithm in 66% of these patients.

The factors likely to increase the risk of unreliable PE diagnosis were the presence of congestive heart failure (NYHA class III-IV), renal failure (GFR <30ml/min) and pregnancy. Furthermore, the diagnostic strategy was reliable, according to the ESC guidelines, in only 67% of high risk patients. Consequently, hospital mortality was significantly related to adherence to validated PE diagnostic assessment. Unreliable diagnosis of PE was an independent risk factor for all-cause in-hospital mortality (OR 2.26 (95%CI: 1.52-3.36)). The same was also true for mortality at 90 days. This underlines the importance of adhering to clinical practice guidelines in this setting.

Manuel Monreal reported data from the RIETE registry, showing that 24% of patients with PE as recruited from daily routine practice, did not meet the criteria for inclusion in a randomized clinical trial. This would indicate that a high proportion of PE cases do not have a suitable profile for clinical studies, because they are more severe. These patients have a significant higher risk of fatal bleeding and fatal PE. Among the bleeding events, in-hospital bleeding (<2 weeks after PE diagnosis) carried a higher risk of death and repeat bleed as compared to later bleeds (>2 weeks). Renal failure (GFR <30ml/min) is also associated with higher risk of fatal PE and fatal bleeding.

Monreal further showed that among patients with venous thrombo-embolic disease, the risk of unfavourable evolution towards fatal PE increases drastically with increasing age, and immobility. Thus, a patient aged >75 years, with non-massive PE and immobility has a risk of fatal PE of almost 25%.

Monreal and colleagues also developed a bleeding score to predict fatal bleeding in patients with PE. By attributing different weights to factors such as metastatic cancer, recent major bleeding or advanced age and immobility, amongst others, this score identifies three groups at high, intermediate and low risk for fatal bleeding.

Stavros Konstantinides went on to provide additional information about diagnostic and therapeutic strategies for PE at intermediate risk, defined by the association of right ventricular dysfunction on echocardiography and myocardial injury in hemodynamically stable patients. The difficulty in this situation is that, when taken individually, biomarkers (troponin I or T, BNP or NT-proBNP) or echocardiographic or CT scan evidence of RV dysfunction do not have sufficient sensitivity and specificity to predict early PE-related death. The potential contribution of new biomarkers (high sensitivity troponin T, heart type fatty acid binding proteins (H-FABP) or growth differentiation factor-15) was also mentioned as promising avenues of research.

Konstantinides also spoke about the ongoing Pulmonary Embolism International THrOmbolysis trial, which aims to evaluate the clinical benefits (efficacy) and safety of thrombolysis (tenecteplase) in intermediate-risk PE patients, defined as RV dysfunction plus myocardial injury. The main endpoint is all cause mortality within 7 days or haemodynamic collapse within 7 days that requires cardiopulmonary resuscitation. The study plans to include 1110 patients, of whom 529 have already been accrued.

The last speaker, Arnaud Perrier, discussed whether the time has come to update the ESC guidelines on management of PE. He emphasised the importance of diagnosis, particularly the use of clinical scores, which, although accurate, are quite complicated and little used in routine practice. There is a pressing need to develop simpler scores, as has been done with the PESI score (Pulmonary Embolism Severity Index).

Also in terms of diagnosis, Perrier showed that MRI results have been disappointing, with almost one quarter of MRI exams being technically inadequate, and only 78% sensitivity among patients with adequate MRI quality. He also insisted on risk stratification and its usefulness, which remains to be demonstrated in unequivocal terms. Indeed, clinical assessment is better than biomarkers in defining low risk PE. Although biomarkers have a high negative predictive value, the positive predictive value is low.

As regards treatment, Dr. Perrier mentioned the advent of new drugs with expected better efficacy-safety profiles, which could make it possible to consider long-term anticoagulant treatment as a realistic option. In particular, he mentioned dabigatran (RECOVER Study), which was shown to be as efficacious as warfarin, with fewer bleeding complications. The results of the ongoing EINSTEIN-PE study are keenly awaited.




Acute pulmonary embolism - 2010
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.