Prof. Stavros V. Konstantinides
The purpose of this session was not to simply present the existing guidelines on the management of acute pulmonary embolism (PE), and much less so to repeat those recommendations which are based on strong evidence and are therefore unequivocal. Instead, the session identified and focused on difficult, controversial issues and clinical scenaria, which are controversially discussed even among experts. First, Professor Steen Husted presented the case of a pregnant patient with suspected acute PE. No clear evidence exists regarding the optimal diagnostic and therapeutic approach to these patients. There was general consensus within the panel that d-dimers are too frequently elevated in pregnancy to be of practical use. A large part of the session attendees favoured the use of compression ultrasound of the leg veins as the first-line diagnostic imaging examination, but the panel strongly recommended prompt, reliable diagnosis or exclusion of PE by a computed tomographic (CT) examination. A perfusion lung scan was also proposed as a good alternative if the patient has a normal chest X-ray, which can be done upon admission without significant radiation exposure. For therapy, there was consensus on the efficacy and safety of low molecular weight heparins (LMWH). Several strategies were discussed regarding the need for monitoring anti-Xa levels and for adjusting the dose. In general, neither anti-Xa-activity testing nor frequent adaptations of LMWH dosage were advocated, and one of the panel members emphasized that leaves the dose unchanged throughout pregnancy. Then, Professor Guy Meyer discussed the dilemma on whether to administer thrombolysis to a normotensive patient who has signs of a dysfunctional right ventricle on the echocardiogram and a positive biomarker test. Many attendees felt that thrombolysis may be indicated if the clinician’s impression is that the patient’s respiratory or haemodynamic status is progressively deteriorating while on anticoagulation. However, it was emphasized that only the 1,000-patient Pulmonary Embolism Thrombolysis Study (PEITH), which has just completed patient recruitment, will be able to provide an answer to this question. The results of PEITHO are expected in early 2013. Finally, Professor Huisman confronted the attendees and the panel with the case of a patient with “low-risk PE” who may be eligible for immediate (or early) discharge and home treatment. Home treatment of PE is still controversial despite the positive outcome of a recent randomized study which used the PESI criteria to identify the appropriate candidates for early discharge. Prof. Huisman argued that the PESI score was not conceived tor this purpose, and defended instead the utility of the Hestia criteria, which have been successfully tested in a prospective cohort study and are currently undergoing evaluation in a randomized trial in the Netherlands. It was also emphasized that new oral anticoagulants will need to be tested in this context, as they may substantially simplify early treatment of acute PE and improve patient compliance. The session was not meant to finally resolve all these controversial issues, but it succeeded in generating a fruitful discussion and was well received by the attendees who participated actively with numerous practical questions and comments. At the end of the session, the participants had become aware of the expert opinion and current trends in the management of 1) PE in pregnancy, 2) intermediate-risk PE, and 3) home treatment of PE, and of the ongoing studies which may soon advance our knowledge in these fields.
Challenges in the management of acute pulmonary embolism
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