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Vascular
Pulmonary Embolism (PE): Diagnosis & Management
Added by Dr. Andrew · Last updated 2024-01-15
Overview
Pulmonary embolism is a potentially life-threatening condition caused by thrombus (or other material) obstructing the pulmonary arterial circulation. Risk stratification guides treatment intensity, from anticoagulation alone to systemic thrombolysis or surgical embolectomy.
Key Points
- 1Risk stratification: massive (hemodynamically unstable) → submassive (RV dysfunction, elevated troponin/BNP) → low-risk
- 2Diagnosis: CT pulmonary angiography (CTPA) is gold standard; V/Q scan for renal insufficiency/contrast allergy
- 3Wells score + D-dimer: rule out PE in low-probability patients
- 4Massive PE: systemic thrombolysis (tPA 100 mg over 2h) if no contraindications
- 5Submassive PE: anticoagulation ± catheter-directed thrombolysis (ULTIMA, SEATTLE II)
- 6DOAC preferred over warfarin for VTE treatment (EINSTEIN, AMPLIFY, HOKUSAI trials)
Clinical Pearls
- PESI score: predicts 30-day mortality — low PESI allows outpatient treatment
- Right heart thrombus in transit: emergency surgical embolectomy or thrombolysis
- Chronic thromboembolic PH (CTEPH): consider after 3 months of anticoagulation if symptoms persist
- Heparin: start immediately when PE suspected — do not wait for imaging
Board High-Yield
Exam Focus- Massive PE + hemodynamic instability = systemic thrombolysis (absolute contraindications: recent surgery, stroke)
- PEITHO trial: thrombolysis in submassive PE reduced hemodynamic decompensation but increased major bleeding
- Extended anticoagulation: unprovoked PE has high recurrence — consider indefinite DOAC
- CTEPH: surgical pulmonary endarterectomy (PEA) is curative — refer to expert center
- Riociguat: approved for inoperable CTEPH (CHEST-1 trial)
ABIM Exam Weight
6%
Pulmonary Vascular Disease represents approximately 6% of the PCCM certification exam.