HelixTalk Episode #77 - PE: Not Just a Class in Junior High -- Top 5 Clinical Pearls about Pulmonary Embolism

Date posted: April 24, 2018, 6:00 am

In this episode, we discuss five clinical pearls about pulmonary embolism ranging from PE diagnosis, classification, and treatment. We specifically examine when and how alteplase is given for PE and its use with concurrent anticoagulation.

Key Concepts

  1. A CT scan with contrast (CTA or CT angiography) is the most common diagnostic test to make the diagnosis of PE.  The decision to actually do a CTA is based on the clinical suspicion of PE and sometimes is prompted based on the result of a D-dimer test.
  2. Pulmonary embolism can be classified as “massive” (low blood pressure), “intermediate” (positive biomarkers indicating strain or damage to the heart), and “low-risk” (hemodynamically stable without any damage or strain on the heart).  Massive PE is associated with a significant mortality rate approaching 25-50%.
  3. Alteplase (TPA) dosing and contraindications are very different between massive PE and acute ischemic stroke.  Most notably, the dosing of alteplase is a fixed dose (100 mg) and can be given even if the patient is fully anticoagulated.
  4. Patients with “intermediate” PE are sometimes candidate for alteplase (TPA), but it’s a case-by-case decision.  Of the data that does exist, TPA does not reduce mortality in intermediate PE but it may have a benefit in outcomes related to quality of life, such as pulmonary hypertension, but it does so at an increased risk of major bleeding.
  5. Anticoagulation can be given before, during, and after alteplase (TPA) administration.  Heparin is usually the preferred anticoagulant in this setting because it can be reversed quickly and has a short half-life if major bleeding does occur. 

References

  1. PEITHO study: Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014 Apr 10;370(15):1402-11. doi: 10.1056/NEJMoa1302097.
  2. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315-52. doi: 10.1016/j.chest.2015.11.026.