Podcast 552: PE Management and Risk Stratification

<p><strong>Contributor: Dylan Luyten, MD</strong></p> <p><strong>Educational Pearls:</strong></p> <ul> <li style="font-weight: 400;"><span style="font-weight: 400;">After you diagnose a pulmonary embolism (PE) via CT or VQ scan, we need to categorize the PE as massive, sub-massive, or just PE to dictate treatment.  </span></li> <li style="font-weight: 400;"><span style= "font-weight: 400;">Massive PE: shock with hypotension due to an embolism, and the treatment of choice is thrombolysis with IV tPA with anticoagulation after lysis. Catheter thrombolysis is not used in the hemodynamically unstable patient but can be done after they are stable.</span></li> <li style="font-weight: 400;"><span style= "font-weight: 400;">Sub-massive: signs of right heart strain/failure but hemodynamically stable. This can be EKG changes, positive biomarkers, or imaging findings. These patients can be treated with IV heparin as there may benefit from catheter directed thrombolysis which has been shown to lead to better functional outcomes.  </span></li> <li style="font-weight: 400;"><span style= "font-weight: 400;">Everything else can be stratified to determine whether inpatient even outpatient treatment is necessary </span></li> <li style="font-weight: 400;"><a href= "https://www.mdcalc.com/pulmonary-embolism-severity-index-pesi"><span style="font-weight: 400;"> Pulmonary Embolism Severity Index</span></a> <span style= "font-weight: 400;">(PESI) or</span> <a href= "https://www.mdcalc.com/hestia-criteria-outpatient-pulmonary-embolism-treatment"> <span style="font-weight: 400;">Hestia</span></a> <span style= "font-weight: 400;">criteria and can help determine if the patient is better suited for in or outpatient management.</span></li> <li style="font-weight: 400;"><span style="font-weight: 400;">Non massive or sub-massive PEs are treated with heparin/Lovenox bridged to Warfarin, a factor Xa inhibitor (ex. Xarelto), or direct oral anticoagulants (DOAC).</span></li> </ul> <p><em><span style="font-weight: 400;">Editor’s note: intravenous h