PE Risk Stratification: Oren Friedman interviews Vic Tapson

Welcome to the first episode of PERTCast, the official podcast of the PERT Consortium! Episode 1: Oren Friedman interviews Vic Tapson about risk stratification of the pulmonary embolism patient. Oren Friedman MD Associate Director, Cardiac Surgery ICU  Pulmonary Critical Care  Cedars-Sinai Medical Center Victor Tapson MDProfessor of MedicineDirector, Venous Thromboembolism and Pulmonary Vascular Disease Research ProgramAssociate Director, Pulmonary and Critical Care SectionCedars-Sinai Medical Center PE risk stratification Pearls: history and classifications. Patient's appearance and vitals (initial and trend) are most important parts of risk stratification algorithm. Syncope can have a wide differential. Syncope in setting of PE can have significant consequences. Patient resting comfortably can be reassuring, but at the same time ask- what happens on exertion, to gauge the severity of symptoms (i.e. dizziness, near syncope etc.) Profound hypoxemia is under recognized in PE classification. European Society of Cardiology (ESC) integrates PESI, and sPESI score that is much more practical way of PE classification. ESC classification divide PE into Intermediate PE (Submassive PE) in to two categories- Intermediate high risk (positive sPESI score, RV dysfunction and biomarker positivity) or Intermediate low risk (Positive sPESI score, and RV dysfunction or biomarker positivity). PE classification is heterogeneous, patient's hemodynamics can evolve, so will be their risk stratification score. Biomarkers in PE risk stratification: Troponin more sensitive than BNP. Be careful for false positives (elevated BNP in chronic heart failure) Lactic acid can provide prognostic information in setting of PE. CTA based risk stratification: Contrast reflux into IVC/Liver RV/LV ratio >0.9 Clot burden, 40% occlusion of pulmonary circulation can be associated with high PE related mortality.  Echo based risk stratification: Normal RV can't generate systolic pressure in the excess of 50-60 mm Hg. Elevated PA systolic pressure >70-80 mm HG suggest chronic component of RV failure RV need to have good systolic function to generate high PA pressure TAPSE is not the holy grail of RV dysfunction, interpret with caution. Residual DVT Extensive DVT (above knee) with higher risk PE have worse outcomes. Patient activity (few days to weeks) should be restricted. IVC filter should not be considered in every case of PE with DVT.  Treatment Pearls: Every patient with acute PE should be promptly anticoagulated. Change in vital trends or persistently abnormal vital signs may help in consideration of advance reperfusion strategies in same PE category.  Take home message: Look at patient's appearance + Vitals (HR, RR) and add other objective measures (sPESI, Biomarkers, imaging) + Residual clot burden in risk stratification. Activate the multidisciplinary PERT to leverage input from local experts. References: Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35(43):3033-69, 3069a-3069k. Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383-9. Van der meer RW, Pattynama PM, Van strijen MJ, et al. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology. 2005;235(3):798-803. Prandoni P, Lensing AW, Prins MH, et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016;375(16):1524-1531. Becattini C, Cohen AT, Agnelli G, et al. Risk Stratification of Patients With Acute Symptomatic Pulmonary Embolism Based on Presence or Absence of Lower Extremity DVT: Systematic Review and Meta-analysis. Chest. 2016;149(1):192-200. Grau E, Tenías JM, Soto MJ, et al. D-dimer levels correlate with mortality in patients with acute pulmonary embolism: Findings from the RIETE registry. Crit Care Med. 2007;35(8):1937-41.