Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Acute pulmonary embolism continues to pose diagnostic and management challenges for critical care clinicians.
Speaker: In today's episode of Critical Matters, we will discuss the recently released clinical practice guideline for the evaluation and management of acute pulmonary embolism in adults.
Speaker: The guideline is a report of the American College of Cardiology, American Heart Association Joint Committee on Clinical Practice Guidelines.
Speaker: It was developed in collaboration and endorsed by eight additional professional societies.
Speaker: We are honored to have Dr. Mark Krieger, the lead author and chair of the writing committee for these guidelines as our guest today.
Speaker: Dr. Krieger is a professor of medicine and professor of surgery at the Geiser School of Medicine at Dartmouth-Hitchcock Medical Center.
Speaker: He's also a past president of the American Heart Association, an internationally recognized leader in cardiovascular and vascular medicine with more than 400 scientific publications.
Speaker: Mark, welcome to Critical Matters.
Speaker: Well, thank you, Sergio.
Speaker: It's a pleasure to be here.
Speaker: Thank you for inviting me.
Speaker: First, I wanted to thank you on behalf of the critical care community for such a monumental document and I'm sure effort in these guidelines.
Speaker: I think that they're like over 75 pages, but it is really a wealth of information and discussion.
Speaker: And we are really honored to
Speaker: to have you here today to talk a little bit in more depth about these guidelines and how they should be applied at the bedside.
Speaker: I would like to start with asking you, why is this clinical guideline important for critical care clinicians?
Speaker: Well, I'll respond to that by saying it's important for everyone who takes care of patients who have had a pulmonary embolism.
Speaker: It's really a contemporary roadmap to help all these clinicians navigate
Speaker: the advances for the safest and most effective approaches to care for patients with this condition.
Speaker: So it includes treatment recommendations by care setting.
Speaker: That includes which patients can be discharged from the emergency department and managed as outpatients, which patients require hospitalization, and apropos to our discussion today, which patients need critical care.
Speaker: Excellent.
Speaker: And what is unique or different about these guidelines compared to guidelines that have been published previously?
Speaker: Well, there's been excellent guidelines that have been published in the past.
Speaker: I'm sure your listeners are familiar with many of them.
Speaker: The CHESS guidelines, of course, have been around for many years.
Speaker: The American Society of Tenetology published guidelines.
Speaker: as well as the European Society of Cardiology.
Speaker: However, there's been no recent guidelines in at least the past five or six years, and this is really a rapidly emerging field.
Speaker: And this is really the first clinical practice guideline from the Joint Committee of the American Heart Association and the American College of Cardiology, which, as you noted in your introduction, really invites other co-sponsoring organizations who really have an interest in this particular area.
Speaker: Before we dive into the clinical recommendations themselves, could you provide a high-level overview of the methodology, and especially if you could explain how these guidelines use class or strength of recommendation and level or quality of evidence?
Speaker: Yes, I'd be happy to.
Speaker: So this is the type of structure for class of recommendation level of evidence that this joint committee has been using since really its inception.
Speaker: the European Society of Cardiology uses a similar type of structure.
Speaker: So let me explain each, and I'll distinguish what the two are.
Speaker: So the class or strength of recommendation is really divided into three major parts, but each has subparts.
Speaker: The strongest class of recommendation is class one.
Speaker: That's a recommendation in which the benefit greatly exceeds the risk,
Speaker: And you'll see verbiage in the actual recommendation, such as this on the blank, this diagnostic approach, this treatment is recommended.
Speaker: Now, class II has two subcomponents.
Speaker: Class IIa is really something that has a moderate recommendation.
Speaker: and it's where the benefit still exceeds the risk, maybe not as much as in a class one recommendation, we use verbiage such as this treatment is reasonable.
Speaker: A class 2B, it's a weaker recommendation, still one that we think benefit exceeds risk, and verbiage we might be using in these recommendations as this treatment may be reasonable or might be considered.
Speaker: Class III is a recommendation that indicates either no benefit, so the treatment has not been shown to be effective, so benefit equals risk, and there's another section in Class III which is harm.
Speaker: A particular treatment could be potentially harmful where risk exceeds benefit.
Speaker: So those are the classifications we use.
Speaker: And then to support these classifications, there's different levels or quality of evidence.
Speaker: ranging from A to C, and they each have subcomponents as well.
Speaker: So level A is the highest quality of evidence.
Speaker: It typically comes from more than one randomized controlled trial or meta-analyses of high-quality randomized controlled trials.
Speaker: Level B is divided into two.
Speaker: Those that the evidence are randomized, at least one randomized clinical trial or meta-analysis of a moderate-quality randomized clinical trial.
Speaker: or data that comes from non-randomized trials such as observational studies or registry studies.
Speaker: Level C, well, that would be the least quality of evidence.
Speaker: It has two components.
Speaker: One is it's just limited data, so there's some papers out there that address the particular topic, but not strong papers.
Speaker: Or expert opinion in which there really isn't much of a literature study
Speaker: But it's members of the running committee getting together and saying, listen, we don't have clinical evidence to support this, but in our experience, this seems to be an effective thing.
Speaker: That's the lowest level of evidence.
Speaker: And I think what's always important is to emphasize to our readers that what the committee does is reviews all the available evidence as experts discuss.
Speaker: And many times you are constrained to what studies are out there.
Speaker: And in some of these areas, like you mentioned, 2B, 2A recommendations, which we have, it's just that we just don't have enough studies of enough importance to really make a stronger recommendation, correct?
Speaker: That's right, Serger.
Speaker: So we spend a long, long time discussing the evidence for any particular recommendation.
Speaker: We do publish the evidence that we use to support the recommendations as a supplement.
Speaker: And then when one reads the recommendations in the actual guideline, at least the high-level recommendations where there is literature supported, that literature is cited.
Speaker: Excellent.
Speaker: Let's dive into the recommendations and the clinical guideline itself.
Speaker: And I want to start with diagnosis of acute pulmonary embolism.
Speaker: And there are a lot of areas we could focus on and won't discuss today, but I would refer this to our audience to read the guidelines because there's a lot of novelty also in terms of
Speaker: how we can maybe send some of these people home, which is something that I had never experienced during training.
Speaker: But in terms of diagnosis, could you talk about the role of risk scores and D-dimer, and then we can dive into the role of imaging both CTA and echocardiography today?
Speaker: Right.
Speaker: So this really refers to the art of being a doctor.
Speaker: A patient comes in, in this case, often to an emergency department, but it could be a physician's office, with certain complaints and certain findings.
Speaker: And it's really up to the clinician to get a good understanding of what the history is and what the physical findings are.
Speaker: and then incorporate that information into one of a variety of clinical decision tools, which will help the clinician decide whether there is a low probability or a high probability or intermediate probability of pulmonary embolism.
Speaker: And there's a number of these clinical decision tools out there.
Speaker: An example, one your audience will be most familiar with may be the Welles score.
Speaker: There's a revised Geneva score, there's a pulmonary embolism rule-out criteria.
Speaker: All of these can be used really to synthesize the history and the physical findings and inform a clinical pretest probability of pulmonary embolism.
Speaker: So first and foremost, that's what we're using as we now go through our algorithm as to whether we need to do any further diagnostic testing.
Speaker: So when you use these decision tools, and a lot of this is intuitive, I should say, but being more objective and structured and using the decision tools, if someone has a low probability of pulmonary embolism, like the Wells score is partially zero, then one might consider, if you're still worried about it,
Speaker: getting an age-adjusted D-dimer value and see whether or not it's elevated.
Speaker: If the probability based on your risk assessment is low, it could be lower or intermediate to, let's say, less than 50%, and the D-dimer level is below threshold, then you've really effectively excluded a pulmonary embolism and don't need to do any further diagnostic testing like imaging.
Speaker: However, if you're dealing with a case where the clinical pretest probability is elevated and the D-dimer level is elevated, either one of those things, then you're really moving on a path for additional diagnostic testing.
Speaker: We can talk about what the diagnostic testing would be, but I think
Speaker: The benefit of a clinical decision tool and the D-dimer is really to exclude the likelihood of pulmonary embolism if these values are low.
Speaker: And one aspect of practice that we obviously are not facing right now is in the context of this conversation, we're very focused on pulmonary embolism and we're not being distracted like many of our emergency medicine colleagues are, maybe even a clinician in his office with multiple inputs on other patients and problems here, problems there.
Speaker: So really using, I guess, the framework, the clinical objective framework is a great starting point to really figure out, okay, what really is going on here?
Speaker: And like you said, a D-dimer can help you rule out pulmonary embolism in the right context, but it's not diagnostic.
Speaker: So let's say that we now are moving forward and want to image, we need to say, well, I need imaging confirmation.
Speaker: What is currently recommended by the guidelines as our go-to test?
Speaker: Right.
Speaker: So I...
Speaker: Again, the majority of these patients will be coming to an emergency department, right?
Speaker: They have the ketones that have chest discomfort or they've gotten very short of breath and they're anxious.
Speaker: Some more severe cases, they might have had a syncopal episode, but in either case, they're showing up at the emergency department.
Speaker: Virtually every emergency department, not only at tertiary hospitals, but most community hospitals, has a CT scanner right next to the emergency room.
Speaker: So really the go-to test, the one we're recommending, is a CT scan to look for pulmonary emboli.
Speaker: So CTPA, CT pulmonary angiogram.
Speaker: It's widely available, it's accessible, it's got a relatively reduced overall cost burden compared to other testing.
Speaker: Currently radiation exposure is relatively low, and importantly,
Speaker: It has excellent diagnostic performance.
Speaker: So that's really our go-to test.
Speaker: Now, I think, again, your listeners will know, well, there's other tests like a VQ scan.
Speaker: But, you know, today, VQ scans are much harder to get.
Speaker: They're not outside the emergency room.
Speaker: It takes a little while to order them and get them done.
Speaker: And although they're good, they're not as good as a CT scan.
Speaker: So,
Speaker: If there's no contraindication to the CT scan, that's what we're recommending.
Speaker: Perfect.
Speaker: And I believe that most patients, well, I would rephrase that.
Speaker: Every patient I see as a critical care doc who has a PE should have an echocardiogram, but not to make the diagnosis, like some people who are very enthusiastic about bedside ultrasound today might propose, but what's the role of echocardiography in these patients?
Speaker: Well, Sergio, I'm sorry to disagree with you a little bit,
Speaker: But I wouldn't say that every patient with a PE needs an echocardiogram.
Speaker: And we're going to talk a little bit later in this podcast about the different clinical categories.
Speaker: But there are clinical categories where an echocardiogram is extremely helpful.
Speaker: When you really want to determine whether a right ventricular dysfunction is present to help you develop some prognostic indicator information.
Speaker: of how well the patient will or may not do.
Speaker: So we certainly do, and the writing committee certainly recommends echo, particularly in those patients who have clinically significant pulmonary emboli.
Speaker: And we'll talk about who that is.
Speaker: And I just want to clarify.
Speaker: So like I said, every patient I see as an intensivist.
Speaker: So I agree.
Speaker: Yeah, yeah.
Speaker: But I think if they're coming to the ICU, I want to have an echocardiogram.
Speaker: Would you agree with that statement?
Speaker: You're seeing the group that should get an echocardiogram.
Speaker: Okay, perfect.
Speaker: So from a critical care perspective, absolutely yes.
Speaker: But again, as we're going to talk about, there are people with incidental pulmonary emboli with no symptoms.
Speaker: And they may not, in most circumstances, need to not go.
Speaker: Perfect.
Speaker: This is, I think, the adequate lead to our next topic, which is something that is novel of these guidelines and that I hope helps clinicians talk the same language.
Speaker: I believe that being very precise when we talk about diseases helps different disciplines understand disease.
Speaker: what we're talking about when we're giving report, when we're trying to send somebody to another institution.
Speaker: The NIH score has done that for stroke.
Speaker: I know that the shock SCI classification has helped that in terms of deciding on mechanical circuitry support.
Speaker: And now I want you to tell us a little bit more about the AHA, ACC acute PE clinical categories.
Speaker: Great.
Speaker: Well, thank you for bringing that up, Sergio.
Speaker: I think this is certainly the most novel and really potentially most impactful parts of this categorization of the HAACC PE guidelines.
Speaker: So, again, your listeners will recall that years ago, we kind of thought of pulmonary emboli as stable or submassive or massive, and
Speaker: In part, that was based on a scientific statement by the AHA.
Speaker: But that really wasn't as helpful as we would have liked it to be in helping us define how severe the patient is and how to manage them.
Speaker: The European Society of Cardiology, in their guidelines, published I think in 2019, really put forward categorizations of low-risk,
Speaker: intermediate risk, which was subdivided to low intermediate risk and high intermediate risk and higher risk.
Speaker: And I think most everyone has been using those category categories.
Speaker: Since that time, it certainly has informed management and it has informed the clinical research in such a patient's particular studies is designed to study.
Speaker: Well,
Speaker: We felt that we really need to break that down a little bit better to really help us figure out what the likely risk for an adverse outcome would be and also to help us more precisely determine which might be the most effective and safest therapy.
Speaker: So with your permission, Sergio, I can go in and discuss what they are in more detail.
Speaker: Please, absolutely.
Speaker: Okay.
Speaker: So there are, we're using letters here.
Speaker: first five letters of the alphabet, A, B, C, D, and E, for each of our major PE clinical categories.
Speaker: And then a number of these categories are subdivided into more specific clinical presentations.
Speaker: So, category A, this we're calling subclinical.
Speaker: These are patients who are asymptomatic and
Speaker: Oftentimes, their PE is diagnosed incidentally.
Speaker: So an example might be someone who's being managed for cancer, and they're getting periodic imaging, chest CTs, to see whether there's been any change in the presence of the cancer.
Speaker: And in one of the CT scans, a pulmonary embolism is felt.
Speaker: So the patient has a pulmonary embolism.
Speaker: It's an incidental finding.
Speaker: They're not having any symptoms from it, and that's subclinical.
Speaker: That's A. With B, the patient does have symptoms, but in their 30 score,
Speaker: The symptoms, it's a low number.
Speaker: So a low number in terms of the different clinical severity scores we use.
Speaker: We'll talk about that in a minute.
Speaker: PESI might be one, the pulmonary pulmonary pulmonary pul
Speaker: The embolism severity index might be one familiar to your listeners.
Speaker: So B is the symptomatic patient, some shortness of breath, maybe some chest pain, low clinical severity score.
Speaker: And on their CT angiogram, they'll have single or multiple subsegmental defects or maybe subsegmental defects.
Speaker: That's B1 and B2, respectively.
Speaker: Category C, so they're getting more severe now.
Speaker: with elevated clinical severity scores.
Speaker: And we've divided that into three major sections plus one modifier.
Speaker: And again, I encourage everyone to actually look at our chart that we use to define this because as I speak now, it'll be more and more complex until you really get a good feel of it from our chart.
Speaker: So C is symptomatic patients with an elevated clinical severity score.
Speaker: C1 is
Speaker: They have a normal right ventricular size and function and normal biomarkers such as troponin or NT-proBNP.
Speaker: So that would be similar to the ESC low intermediate score.
Speaker: Z2 is
Speaker: the individual will have, get an elevated clinical severity score, plus either one abnormal biomarker, or at least one abnormal biomarker, or abnormal right ventricular size and function.
Speaker: And then C3, again, a patient with an elevated clinical severity score, they're symptomatic, and they have both
Speaker: an abnormal right ventricular size and function on your echo, for example, and at least one abnormal biomarker.
Speaker: So that's just progressing up the scale, C1, C2, C3, breaking down what had been the intermediate risk categories.
Speaker: And then we've added another category called a respiratory modifier, either present or absent.
Speaker: And in the respiratory modifier, it would include things such as low O2 saturation, less than 90%, an elevated respiratory rate creating 30%, or the need for supplemental oxygen.
Speaker: Category D, these folks are getting pretty sick, and you're going to be seeing them in the care units.
Speaker: So we define this as incipient cardiopulmonary failure.
Speaker: There's two subcategories, transient hypotension.
Speaker: So for a period, they've dropped their systolic blood pressure under 90, or their mean arterial pressure under 60.
Speaker: That's D1, or D2 is normotensive shock.
Speaker: I'm sure your listeners are wondering
Speaker: familiar with.
Speaker: Now these are folks who may not have a systolic blood pressure less than 90, but they're showing evidence of shock by end-organ dysfunction and elevated lactate.
Speaker: And this too has a respiratory modifier, which is positive if they need more than six liters of nasal cannular or use of a non-rebreather mask.
Speaker: The highest risk is E, that's cardiopulmonary failure, that has two subsets.
Speaker: that they have resistant or persistent hypertension with cardiogenic shock and E2 they have refractory cardiogenic shock or cardiac arrest and they too have a respiratory modifier and it's positive they have hypoxemic respiratory failure or ventilatory failure.
Speaker: So that's an overview of the HAACC QPE category.
Speaker: And I would encourage, like you mentioned earlier, Mark, that our listeners will reference the publication of the guideline in circulation.
Speaker: People should be reading these, looking at these figures, because it can help us communicate in between disciplines.
Speaker: We'll talk about
Speaker: pulmonary embolism response teams a little bit later, but making sure we're all understanding the severity of the patient.
Speaker: But also what's very important is that a lot of the therapeutic interventions and management decisions are really framed around these subcategories as we dive deeper into the guidelines.
Speaker: So I really think this is phenomenal.
Speaker: It gives us a very...
Speaker: coherent.
Speaker: It makes sense.
Speaker: I mean, as an intensivist, I look at this and it makes sense and it just helps us maybe select our patients a little bit better for some of these advanced therapies.
Speaker: That's right.
Speaker: And I'd say at first pass, it seems pretty complex, more complex than it had been, but it's really quite useful.
Speaker: And, you know, someone like me, who's now been thinking about this for a long time, it's second nature.
Speaker: And even my trainees are now using it pretty routinely.
Speaker: on their office notes.
Speaker: And what I think is going to be extremely valuable is, I'm in Houston, you're in Lebanon, and if I were to call you and say, I have a D1R, you know exactly what I'm talking about, right?
Speaker: That's very correct.
Speaker: Absolutely.
Speaker: Excellent.
Speaker: Well, the real meat of the discussion really is in how do we manage these patients, right?
Speaker: The acute management.
Speaker: And what I would like to do is use the classification you just shared to maybe walk down some of the recommendations that are most relevant on management.
Speaker: I didn't count the total recommendations, but there's quite a bit.
Speaker: You probably know that top of your head, but it's a very long document.
Speaker: We're not going to cover everything.
Speaker: Our focus is going to be some of the highlights and most important take-home messages for the acute management, especially from the perspective of patients who will be coming to the ICU.
Speaker: And in my experience, Mark, usually these are going to be C2 and above.
Speaker: But for sure, D and E need to be in an ICU.
Speaker: See, I guess you could discuss what type of treatment they're getting and what infrastructure you have in your hospital.
Speaker: But the beauty also here is that category A and B probably are not going to be treated in the ICU for sure, but maybe not even as inpatients, right?
Speaker: These can be treated as outpatients.
Speaker: Correct.
Speaker: Yeah, you're definitely going to be seeing the Ds and Es.
Speaker: But you're also going to see the C3s depending.
Speaker: I mean, if they're showing signs that they're starting to deteriorate, they're going to the critical care unit.
Speaker: So, yeah, I would say from C3 on up, they're all candidates for critical care unit.
Speaker: So we'll focus on those categories and want to start with first recommendation in terms of treatment.
Speaker: For these patients, what's the current recommendation for acute anticoagulation?
Speaker: So as you're starting to sort things out, right, they're in the hospital, you're not ready to send them home, clearly.
Speaker: We're recommending low molecular weight heparin.
Speaker: Just get the manicuridate, get things going.
Speaker: We do indicate that we prefer low molecular weight heparin over unfractionated heparin for a number of reasons.
Speaker: And that's different from what many people are currently doing.
Speaker: But the reason we're recommending low-molecloid heparin, which is based on the literature and large-med analysis, is that, one, it's easy to use.
Speaker: Two, you get steady-state anticoagulant levels, you know, with fixed dosing.
Speaker: Using unfractionated heparin, it's hard.
Speaker: It's hard to just, you know, titrate up, find the right dose, make sure you're not overshooting, make sure you're giving enough.
Speaker: And so it's much more tedious to use and monitor.
Speaker: So we're recommending that they get a parenteral anticoagulation, and preferably initially with low-molecoid HEPA.
Speaker: And this is like you mentioned, different to what many people grew up using in the ICU.
Speaker: I think the dogmatic approach was if they're sick enough to be in the ICU, unfractured and heparin,
Speaker: like maybe had a little bit more control of stopping and we got into trouble.
Speaker: But you're right.
Speaker: Those of us who've trained many years ago would spend a great majority of our time as residents and interns adjusting heparin drips right before protocols.
Speaker: And it's very hard to get it right.
Speaker: Yeah.
Speaker: So clearly.
Speaker: And that is the concern, but, you know, stopping.
Speaker: Yeah, you can do that and lose efficacy quickly with unfractionated heparin.
Speaker: These patients need anticoagulation, and they're at higher risk of bleeding.
Speaker: You'd have to stop with unfractionated heparin than low-molecoid heparin because of the chance of overshooting the dosing retribute.
Speaker: So clearly that is a class of recommendation one.
Speaker: So recommended and supported, like you said, by the evidence.
Speaker: In terms of risk assessing, you mentioned lactate.
Speaker: We mentioned cardiac biomarkers.
Speaker: Could you expand on those?
Speaker: Well, yeah, for the lactate, you know, and...
Speaker: the critical care docs know this as well as any, the clinical presentation may not really reveal how potentially sick the patient is.
Speaker: You take a category C3, they're symptomatic, they have a high clinical severity score, RV dysfunction, elevated biomarker, and then you draw a lactate and it's elevated.
Speaker: That's an uh-oh.
Speaker: These patients are not doing well.
Speaker: So it's really very informative to really help decide just how sick the patient may be, and that would move them really already from a C3 into a category D. The biomarkers help figure out, they're really to help subdivide the C category from those are C1, their symptomatic elevated clinical severity score, C2,
Speaker: and C3, C2 having, as I mentioned earlier, RV dysfunction and or an elevated biomarker and C3 having everything.
Speaker: So for that category in particular, we find biomarkers are helpful for further subdividing the prognostic indicator.
Speaker: And as biomarkers, we understand CK and BMP.
Speaker: Is there anything else that you would consider?
Speaker: Yeah, pro-BMP.
Speaker: I haven't used CK in many years.
Speaker: Troponin.
Speaker: Troponin, sorry, yeah.
Speaker: So cardiac enzymes, yeah, and pro-BMP.
Speaker: Yeah, I knew that's what you meant.
Speaker: Yeah, so a troponin level, whatever the institution is using.
Speaker: Yeah, perfect.
Speaker: And then the BMP or NT pro-BMP, yeah.
Speaker: And I like the lactate discussion because I've been in practice long enough and both of us have that
Speaker: Lactate was not something we usually measured.
Speaker: Then everybody started measuring for sepsis, and some people thought it was diagnostic for sepsis, but it's not, right?
Speaker: It's more of a marker of hyperperfusion to end organ damages.
Speaker: And now, I mean, we're thinking of shock in a more broad context, where it's cardiogenic shock, where it's PE-induced shock, obstructive shock, or septic shock.
Speaker: The lactate is a marker of severity, and it helps us sometimes identify patients who
Speaker: who are in shock without having a low blood pressure, and that's what we're aiming for here in PE as well.
Speaker: That's right.
Speaker: And all the biomarkers as well as lactate, they're readily available in most hospitals, and you can get your analysis fairly quickly.
Speaker: Yeah.
Speaker: And the truth is that most patients who come to the ED with any sort of cardiopulmonary complaint and are moderately or more sick are going to get these anyways, right?
Speaker: It's just applying them in the right way so we can classify these patients very quickly and then guide therapy.
Speaker: Now, the other aspect of this management from a diagnostic or recertification that's very important is evaluating RV size and function.
Speaker: Could you talk about what's recommended here and how we should proceed?
Speaker: Well, we recommend either a CT, which all these patients have anyway, to get the sense of RV size, and or an ECHO, which will give you size and function.
Speaker: I think, as you indicated earlier, they've had this ET, but the echo is really going to give us a lot more information in terms of how the RV is functioning, how big it is, and also whether there's evidence of pulmonary hypertension.
Speaker: So if patients C3 are higher up to E1,
Speaker: We recommend the assessment of RV, and I think EDECO is the right tool to use.
Speaker: And again, most places, well, not everybody's going to have them, but all major hospitals with critical care units.
Speaker: I shouldn't say all because I don't know that for sure, but most will have availability of EDECO.
Speaker: Yeah.
Speaker: Well, and those who don't should be working towards getting it right because it's a tool that is just extremely useful in guiding therapy for these patients in many situations.
Speaker: Now, I did notice that if you are in the category E2 and you might be on VA, you're not recommending measuring the RV function.
Speaker: Is that just because it's obvious that it's a problem?
Speaker: Well, absolutely.
Speaker: It's not that we're not, we don't recommend it for that because these people are, they're, they're crashing.
Speaker: Yeah.
Speaker: I mean, they're, so you can squeeze and echo in there fine, but you know, they, they need, something needs to be done quickly and we're recommending it's a two way, sorry, a, it's a two way recommendation for VA ECMO.
Speaker: Yeah.
Speaker: So this is a refractory shock or cardiac arrest with PD.
Speaker: Right.
Speaker: Correct.
Speaker: Yeah.
Speaker: Okay.
Speaker: I mean, you already know they're pretty sick.
Speaker: Yeah, no, I agree.
Speaker: And maybe the echo comes later just, I mean, to figure out what else is going on for sure.
Speaker: Before we jump into the pulmonary embolism response team, which I want to have as a separate discussion, could you comment on vasopressor and or inotropic therapy?
Speaker: Is there any particular agent that's recommended?
Speaker: And this is obviously for category D2 and above.
Speaker: Yeah, well, in our recommendation-specific text, which accompanies each of the recommendations, we talk about the data supporting drugs such as norepinephrine and vasopressor based on their vasoconstrictive properties primarily to view them as vasopressor agents.
Speaker: But, you know, it really depends on the individual's
Speaker: practice preference.
Speaker: But those are the vasopressors we would use.
Speaker: But of course, there's other combined vasopressor inotropes that would be certainly acceptable.
Speaker: So clearly, we've talked about risk stratifying these patients, using this new classification, starting low molecular weight heparin in these patients.
Speaker: And now we're going to dive into the area where, I don't want to say controversy, but when there's more discussion.
Speaker: And these are the first guidelines that address this in a more global way.
Speaker: But a systemic thrombolysis has always been a part of our
Speaker: toolkit, we've always recognized that for patients who are in shock, crashing, or very sick, we would consider it.
Speaker: These guidelines recommend D1 and above for systemic thrombolysis.
Speaker: Is that correct?
Speaker: Yes.
Speaker: So for the D1 and D2 category, we give it a 2B recommendation, assuming it's acceptable bleeding risk.
Speaker: Yeah, systemic thrombolysis for the E categories, E1 and 2.
Speaker: It's a two-way recommendation.
Speaker: If the bleeding risk is acceptable on those patients?
Speaker: Oh, yeah, in all circumstances.
Speaker: For systemic thrombolysis, yeah, it has to be an acceptable bleeding risk.
Speaker: Now, the other two therapies that are increasingly available in hospitals are catheter-directed lysis and mechanical thrombectomy.
Speaker: And there has been a tremendous push to get patients these therapies.
Speaker: Intuitively, they make sense.
Speaker: They're cool.
Speaker: I've seen, unfortunately, in hospitals around the country that a lot of C3s and C2s are being treated with these therapies.
Speaker: And the guidelines are saying that in those two categories, we just don't know.
Speaker: Is that correct?
Speaker: Yeah, the guidelines are very cautious about our recommendations for this.
Speaker: So...
Speaker: For the C categories, particularly C2 and even C3, there is really insufficient data.
Speaker: So we give it a 2B recommendation.
Speaker: We indicate it's a level of evidence C, a low level of evidence.
Speaker: It's really unclear whether catheter-directed lysis or mechanical thrombectomy has a role in C2 or C.
Speaker: there's insufficient evidence to support their use.
Speaker: And yes, these therapies are certainly becoming widely available.
Speaker: Many interventionists have a lot more opportunities to use it.
Speaker: But the data is really emerging, and I'll talk in a minute about the data to support that.
Speaker: For the sicker patients, the D1 and D4,
Speaker: B2, it's still a 2B recommendation.
Speaker: We don't have a lot of outcome data yet, long-term outcome data and heart outcome data.
Speaker: So, you know, as you said, intuitively it seems to make sense, and we all have anecdotes that these patients seem to be getting better, and there are studies that show that initially the RV size and function gets better, hemodynamics improve, but again, long-term data is still lacking.
Speaker: And for E1, because these people are so sick, we've given it a 2A recommendation, but level of evidence seen, we really don't have good data.
Speaker: So in terms of these sicker patients, D1, D2, the recommendation still is if there's no like severe contraindications to go with systemic thrombolysis over these, is that correct?
Speaker: Oh, comparatively speaking?
Speaker: Yes.
Speaker: No, we don't have data, good data.
Speaker: to really compare systemic thrombolysis to either of these things.
Speaker: The data we have that's been out there, as I mentioned, there's about at least a half a dozen studies that have compared clinical thrombectomy to anticoagulant therapy, catheter-based lysis to anticoagulation therapy.
Speaker: There's more data looking at systemic thrombolysis versus anti-cardiome therapy alone.
Speaker: But taking together, the outcomes are short-term, and I hesitate to use the word surrogate outcomes.
Speaker: There are reasonable outcomes in terms of RV function, reasonable outcomes in terms of hemodynamics, pulmonary artery pressure and whatnot.
Speaker: But when you look at important outcomes to the patient and the patient's family, death, further deterioration, compensation or collapse, the available studies really don't provide that information.
Speaker: But there's a whole bunch of studies coming up, high PYTHO,
Speaker: It's actually going to be presented at the end of the month at the American College of Cardiology meeting in New Orleans.
Speaker: So this is comparing catheter-directed thrombolysis to anticoagulation.
Speaker: Its primary outcome is a seven-day composite outcome of PE-related death, decompensation or collapse, PE recurrence or clinical criteria for deterioration.
Speaker: So that'll be the first of these that'll really give us a better indication of the efficacy of catheter-based
Speaker: thrombolysis peerless 2.
Speaker: I'm not sure exactly when that will be reported.
Speaker: That's comparing mechanical thrombectomy to anticoagulation.
Speaker: That has a positive endpoint as well, all-cause death in 30 days, decompensation, readmission in 30 days, that kind of thing.
Speaker: And then there's others that we'll be reporting out at some point, PE tracks, which compares catheter-directed thrombolysis to mechanical thrombectomy and a few others as well.
Speaker: So I think in the next, certainly in the next month and then in the next year and the next couple of years, we'll have harder data to really refine these recommendations.
Speaker: Excellent.
Speaker: And I do believe like the guidelines you expressed in the cautioners, I think we should all encourage the studies.
Speaker: We want to get the data at the end.
Speaker: We want what's best for our patients.
Speaker: But I think we've been fooled before, right?
Speaker: Jumping on certain therapies and then they don't have the outcomes that we expected or they have complications that were not measured appropriately.
Speaker: But a lot to come and a lot to discuss.
Speaker: The bottom line is that everybody should get anticoagulation.
Speaker: Everybody should be re-stratified.
Speaker: And as they get sicker, these advanced therapies that include systemic thrombolysis, catheter directed lysis, mechanical thrombectomy, also surgical embolectomy, which we didn't discuss, but I would imagine, Mark, that is less available to our clinicians in most hospitals, right?
Speaker: That's a little bit more specific.
Speaker: specialized probably, should all be evaluated in these sicker patients based on what the information we have and trying to find what's best for that individual patient.
Speaker: And then, yeah, I agree completely with what you're saying.
Speaker: Yeah, cervical embolectomy, there's obviously, there's not a lot of trials and really there's no comparative trials with cervical embolectomy.
Speaker: And, you know, there's,
Speaker: It's not available, as you mentioned, at many hospitals, and it is quite a few.
Speaker: And where it's done and done well, then it's certainly a consideration in the sicker patients.
Speaker: Absolutely.
Speaker: But one aspect that I do want to discuss is the recommendation on the PERT, or the pulmonary embolism response team.
Speaker: And it's interesting because I've heard mixed signals from clinicians around the country on PERTs.
Speaker: but I do believe that they have tremendous value.
Speaker: It may be for a reason that's different than what people are thinking that they should be implemented.
Speaker: Could you talk about how the committee came to recommendation and what are some of the benefits and possible members of this pulmonary embolism response team?
Speaker: Yes, thank you, Sergio, I will.
Speaker: So pulmonary embolism response teams have, I don't remember the exact year they were
Speaker: first talked about, but it's got to be at least 15 years.
Speaker: It was really initiated by folks at Massachusetts General Hospital and started taking off.
Speaker: But we all recognize that it really depends on the hospital, the medical center, what resources, what expertise is available, whether they can put together a pulmonary embolism response team or PERP.
Speaker: But it does have benefits.
Speaker: It's getting a lot of good heads together from different disciplines, which I'll define in a minute.
Speaker: But it does give you diverse insights from these various specialists.
Speaker: It helps foster discussion on the selection and appropriate use of advanced therapies, the implementation of evidence-based protocols and pathways.
Speaker: You know, like our guideline.
Speaker: These are folks who will know these recommendations.
Speaker: They're good for educating our peers and trainees.
Speaker: They foster pathways for appropriate follow-up care.
Speaker: So they really play a good role, an important role, in really thinking about a case and doing it quickly.
Speaker: You know, early on in the patient's interactions with the healthcare teams.
Speaker: Now, it depends on where you are, where the expertise is coming.
Speaker: So I'll mention the types of folks that could be on a pulmonary embolism response team, but different hospitals have different disciplines which are really taking on pulmonary embolism management, and they're the knowledgeable ones.
Speaker: So not everyone on this list should need to be part of a PRT team, but...
Speaker: Certainly many could be or should be.
Speaker: So your pulmonary critical care folks absolutely are important parts of a PERT team.
Speaker: And I should emphasize, we're not calling PERT team for the Class A and Class Bs.
Speaker: There's really not a need for them in those situations, but you're certainly getting Cs and C3s and Ds and Es.
Speaker: You do.
Speaker: So you have pulmonary and critical care.
Speaker: You have C3s.
Speaker: Cardiology, general cardiology, interventional cardiology.
Speaker: I'm a vascular medicine specialist as well as a cardiologist.
Speaker: There's not many of us out there, but when we're very helpful, could be interventional radiology.
Speaker: Hematology in many institutions really plays an important role, a major role in managing these patients.
Speaker: Certainly emergency medicine, when the patient hits the door.
Speaker: Nursing.
Speaker: radiology and pharmacy.
Speaker: I mean, these are all members of the team.
Speaker: Whether they all need to gather at the initial meeting with the patient, no, probably not.
Speaker: But the ones that really are going to be important in decision-making in terms of diagnostic testing and treatment, they really help the patient and help the clinicians managing the patient.
Speaker: who has a pulmonary embolism.
Speaker: And what we do know is it does shorten hospital stay.
Speaker: We're not sure whether or not it reduces mortality.
Speaker: There's more data that's being sought.
Speaker: But they do play a really great role.
Speaker: And I believe that we can learn from other similar teams or similar discussions.
Speaker: I know that in the cancer world, tumor boards involve multiple disciplines trying to figure out in complex cases what is the best path to follow.
Speaker: You have all the disciplines and therapeutic options available there.
Speaker: Now that is usually done with a little bit more time.
Speaker: A PERT team is probably responding in a more time-sensitive manner.
Speaker: but also in shock, cardiogenic shock has grown tremendously with the increase of mechanical circuitry support, getting the right group of people on a call to look at a patient or just at a bedside to decide what's the best mode of action for that patient.
Speaker: It really brings the best of all our expertises to the patient and helps tailor the
Speaker: therapies that might be more appropriate for that individual patient.
Speaker: You mentioned earlier the art of being a clinician and diagnostician.
Speaker: It's also true in terms of finding what are within what's evidence-based, the best therapies for that particular patient.
Speaker: Right.
Speaker: You gave some other great examples, such as the shock team, which are becoming more and more prevalent in many places.
Speaker: And there's institutions that have other teams that work together.
Speaker: Structural heart teams are certainly present.
Speaker: So, yeah, this is just another example of multidisciplinary team care, but in this case, focused on the patient with pulmonary embolism.
Speaker: So clearly in the last several years, there's been an explosion of new therapies, new interest in pulmonary embolism.
Speaker: As you mentioned, Mark, there's a lot of data still not available to us, but there are ongoing clinical trials.
Speaker: that will help us identify the systemic thrombolysis role.
Speaker: When do we go for catheter directed a lysis?
Speaker: Is mechanical thrombectomy better or worse?
Speaker: What are the type of patients?
Speaker: But a PERT team is a great group of
Speaker: clinicians that can respond to each patient, make a more tailored approach, but also as these guidelines continue to evolve, is to make sure that we're implementing the best evidence-based medicine for our patients.
Speaker: Unfortunately, my read right now is that we're overusing some of these advanced therapies, to be honest, and that maybe they should be reserved for good discussion for the sicker patients.
Speaker: Any thoughts on your part on that?
Speaker: Well, you're right.
Speaker: I'm not saying that they're being overused, because I don't know that for sure, but they are being used a lot.
Speaker: We need data.
Speaker: And the data, as I mentioned earlier, is emerging.
Speaker: And that'll help really help all of us refine how we're approaching these patients.
Speaker: But getting knowledgeable people together, people who really understand pulmonary embolism, can only be a good thing.
Speaker: And depending on who's available, what hospital, getting folks from different disciplines, meeting together, discussing a patient, to me makes perfect sense.
Speaker: We do it, as you said, in other areas.
Speaker: And I think if the resources are there, if the expertise is there,
Speaker: then we're recommending that institutions do put together pulmonary embolism response teams if they haven't already.
Speaker: Absolutely.
Speaker: And I hope that we have more of these in the communities and in hospitals and the ones that are functioning continue to evolve and refine their processes.
Speaker: Because this is not also for the sicker patients.
Speaker: It's not one and done.
Speaker: It's not like you get a call when the patient shows up in the ED, what do we do?
Speaker: Because what if it's a C3 that is becoming a D1, now a D2, right?
Speaker: I mean, we have to touch base again and try to figure out, okay, this is what's happening.
Speaker: How do we proceed?
Speaker: Yes, I agree completely.
Speaker: Excellent.
Speaker: The last area that I wanted to discuss, which I believe is important for all clinicians to take care of pulmonary embolism, in our world of the ICU, a lot of times we don't follow these patients once they leave the ICU.
Speaker: Some of our pulmonary critical care colleagues might, but in
Speaker: Post-acute PE management is very important, and it also allows us when we see a patient to give them an idea of what the next 3, 6, 12 months looks like in terms of their medical care.
Speaker: Could you give us the recommendations and anticoagulation by recurrence risk once the patients are ready to leave the hospital?
Speaker: Yes, that's a great question, Sergio.
Speaker: We have an entire section dedicated to this, and it's fairly, I think, fairly well written.
Speaker: First, I would refer the listeners to one of our tables in the guidelines that really reviews the risk factors for venous thromboembolism.
Speaker: I think everyone's...
Speaker: calls using provoked and non-provoked, whether or not patients require long-term anticoagulation or not.
Speaker: But we've really broken it down into major reversible risk factors, minor reversible risk factors, or persistent risk factors.
Speaker: And whether or not these are present would help one decide whether they need long-term anticoagulation.
Speaker: anticoagulation.
Speaker: So for example, someone who's just had a hip surgery, has a pulmonary embolism, that's a major reversible risk factor.
Speaker: We're really recommending anticoagulation for up to three to six months, cases such as that.
Speaker: Then there are minor reversible risk factors, a little less clear.
Speaker: But for example, someone who's
Speaker: had surgery with general anesthesia, but it was a short-term operation.
Speaker: It was under 30 minutes.
Speaker: They were hospitalized less than like three days.
Speaker: It's a little harder to say whether they can be managed with short-term endocrine coagulation or not.
Speaker: So we're leaving that a little vague.
Speaker: But then there are people with persistent risk factors like cancer, autoimmune diseases,
Speaker: inflammatory bowel diseases, those are folks that are going to be constantly at risk.
Speaker: And then we'll recommend long-term anticoagulation.
Speaker: So to put that together, we would say that if there is a patient who's had a PE, does not have a reversible risk factor,
Speaker: doesn't have a major reversible risk factor, then we recommend continuing anticoagulation beyond the initial treatment phase of three to six months into an extended treatment phase, which could be indefinite.
Speaker: If someone has a major reversible risk factor, and I gave one example of that, which was orthopedic surgery, hip surgery, then we recommend stopping the anticoagulation after the initial phase of treatment, which is three to six months.
Speaker: If they have a...
Speaker: persistent risk factor, then continue the anticoagulation for beyond the initial three to six months into an extended phase.
Speaker: And there's other conditions, and again, I encourage reading the document to see where we recommend extended use of anticoagulants.
Speaker: I would also say, though, that there is a lot of data now that support reducing the dose of a DOAC
Speaker: And as you leave the initial treatment phase of three to six months into the extended phase, where you could cut the dose of apixobab, for example, in half from 5 milligrams twice a day to 2.5 milligrams twice a day, similar with gervin roxobab.
Speaker: And also the recommendation in terms of long-term anticoagulation for most patients, whether they're only doing three to six months or extending that, is to use DOACs, correct?
Speaker: Yes, we recommend DOACs in preference to vitamin K antagonists such as warfarin.
Speaker: It's not like the AFib population where...
Speaker: You have to be concerned about mechanical valves or valvular heart disease.
Speaker: No, this is pulmonary embolism.
Speaker: We think there's a lot of good data.
Speaker: terms of, certainly in terms of safety, and in some cases in terms of efficacy of a DOAC over a vitamin K antagonist.
Speaker: And that's a class of recommendation one.
Speaker: That's one.
Speaker: Definitely.
Speaker: And then the other subgroup that's worth mentioning, because we see a lot of these patients, is if the persistent risk is active cancer, low-molecular weight heparin is what they continue on, correct?
Speaker: For active cancer?
Speaker: Yes.
Speaker: No, we do recommend that over Warfarin, but there's now data
Speaker: to support the use of DOACs in patients with cancer.
Speaker: Perfect.
Speaker: So that's also an evolution of the guidelines and a new recommendation.
Speaker: Excellent.
Speaker: The other area on the follow-up that I found very interesting and took to my read at least was novel for PE guidelines,
Speaker: was the importance of really monitoring these patients intentionally for complications and sequela of pulmonary embolism under the category of chronic thrombotic pulmonary disease and many of the complications that can be seen.
Speaker: Could you comment on that, Mark?
Speaker: Well, there's a number of things.
Speaker: Even before that, you know, what we don't want to happen is that the patient is managed well in the hospital, goes home, and then there's no interaction.
Speaker: These patients need follow-up.
Speaker: Again, it depends on the severity of the pulmonary embolism and duration of treatment.
Speaker: But for patients who are being sent home and sent home on anticoagulant, we think we recommend that there be some type of contact in a week.
Speaker: It doesn't have to be in offices.
Speaker: It could be a phone contact.
Speaker: But how are you doing?
Speaker: Let's go over the medication, Geron.
Speaker: Do you have any questions?
Speaker: That kind of thing.
Speaker: And then within three months, an office visit.
Speaker: Again, to see how the patient is doing, make sure they understand their treatment, understand what the pulmonary embolism is about, and have some plans moving forward.
Speaker: And then it really depends.
Speaker: Patients who are doing fine and can be followed by their primary care physician, perfect.
Speaker: But there are patients who have persistent symptoms and are not doing great, and a large percentage of them will, and they may have chronic thromboembolic pulmonary disease and that subgroup chronic thromboembolic pulmonary hypertension.
Speaker: So someone with knowledge should be following these patients as well to decide whether or not they need next steps and really for those who are persistently symptomatic and functionally disabled patients.
Speaker: You know, seeing someone who's really knowledgeable about the long-term consequences of pulmonary embolism.
Speaker: Excellent.
Speaker: Well, we covered a lot, Mark, and there's a lot more that we could cover.
Speaker: Like we said at the beginning, these are quite comprehensive clinical guideline recommendations.
Speaker: We encourage all our listeners to read the document, to share the document with their PERP teams, with their team to discuss it there.
Speaker: There's a lot of very valuable information.
Speaker: Is there anything that we didn't touch on that you really think is relevant to our critical care clinician audience?
Speaker: Well, we did cover a lot, Sergio, and thank you for bringing up all the questions that you did and your comments in our interactive exchange.
Speaker: You already mentioned the 70-plus page document.
Speaker: There's a lot to read.
Speaker: It's not only the recommendations, but the text that supports the recommendations.
Speaker: There's great tables in there and great illustrations, charts, and whatnot.
Speaker: So I just encourage your readers to take a look at it and also to carry around a pocket guideline, which are available for an easy resource.
Speaker: So I'm sure there's a lot of areas we didn't cover in detail just because of the time, but we covered a lot of the important ones.
Speaker: And I really appreciate you asking me the questions that let us discuss these.
Speaker: Excellent.
Speaker: Mark, we like to close the podcast with a couple of questions that are unrelated to the clinical topic.
Speaker: Would that be okay?
Speaker: That would be fine, I think.
Speaker: So the first question relates to books.
Speaker: Is there a book or books that have influenced you significantly or a book that you have gifted often to other people?
Speaker: Well, I'm going to give you two different answers.
Speaker: I love to read.
Speaker: Um,
Speaker: My colleagues and I, our members, we have our own book club, so we do a lot of reading and discussion of books that really range from contemporary novels to really the classics.
Speaker: But what I really like to read is biographies, biographies particularly on American history.
Speaker: So I read quite a bit of those, and it's really helped me understand where our country has been and where it's going and some of the really brilliant people who have influenced our country.
Speaker: I'll just throw two out there that I enjoyed.
Speaker: because of their perspectives.
Speaker: One is Doris Kern Goodwin's team of rivals about Lincoln and his cabinet, really talking about how, you know, talking about pert teams, but how you get people from different perspectives together to help develop policy.
Speaker: And of course, I've certainly enjoyed Ron Chernow's Hamilton and how our, Hamilton's role and how our country was formed and
Speaker: Everybody knows it was made into a Broadway play, a movie.
Speaker: But there's so many other historical books out there.
Speaker: Favorite authors, David McCullough, who unfortunately passed away not so long ago, but others as well.
Speaker: So I really like to read biographies.
Speaker: of folks that have had a major impact in the country.
Speaker: But I read a lot of other things.
Speaker: And both are fantastic.
Speaker: I have, I've read the Hamilton one.
Speaker: I am actually starting a team of rivals.
Speaker: But if people think that the P guidelines are long, they have a surprise with this one, right?
Speaker: Oh, yeah.
Speaker: Now, in terms of book, I give that's altogether different.
Speaker: And this is going to be self-serving.
Speaker: So I apologize.
Speaker: Yeah.
Speaker: But I'm an editor of a book.
Speaker: It's part of Brownwell's Heart Disease.
Speaker: It's a companion to Brownwell's Heart Disease.
Speaker: It's on vascular medicine.
Speaker: And that's what I do.
Speaker: That's what I teach.
Speaker: So that's a book I seem to be giving away because I have lots of copies.
Speaker: And I give them to my fellows and colleagues.
Speaker: Perfect.
Speaker: I mean, all great options.
Speaker: And we'll definitely include links to all these in the show notes.
Speaker: The second question.
Speaker: Go ahead.
Speaker: Sorry.
Speaker: No, I'm, um, yeah.
Speaker: The second question is, could you share something with us that you changed your mind about over the last few years?
Speaker: That's a hard one.
Speaker: Um, I mean, like all of us, my, my thinking evolves.
Speaker: Um, so just like in medicine, uh, it evolves based on, uh, emerging evidence in my own experience.
Speaker: I think that's true in life as well.
Speaker: Uh,
Speaker: So I'm not sure I've changed my mind, but I think I've changed my attitude in a good way.
Speaker: Maybe that comes with growing older and becoming really more thoughtful, more appreciative of what others are doing.
Speaker: So I would say the place I'm at now, particularly the way things are,
Speaker: is to really be patient, listen to others, get others' opinions, and use their opinions and my own learnings to really help me develop my own thoughts on any particular topic.
Speaker: Perfect.
Speaker: And to close, is there something you want every intensivist, a clinician listening to know?
Speaker: Could be a quote or a closing thought.
Speaker: Well,
Speaker: Uh, I think intensivist, first of all, here's another thing that's a bit self-serving.
Speaker: My, my, uh, my son is, uh, training currently to be, uh, an intensivist pulmonary medicine fellow.
Speaker: Uh, I, I, I think it's such an exciting, uh, profession.
Speaker: Uh, intensives do such great work, uh,
Speaker: I admire them, and I love working with them.
Speaker: And I think what intensivists should know is that they're really a critical part of our care team and that should really be engaged really in the discussions of all patients with their colleagues who are not intensivists so that our patients get the best care possible.
Speaker: Perfect.
Speaker: And I think this is a perfect place to stop.
Speaker: Mark, thank you first for the wonderful guidelines.
Speaker: I really can't emphasize enough how much valuable clinical information is in those guidelines, like you mentioned.
Speaker: The graph, the figures, the tables are just really, really powerful, can really help us take better care of our pulmonary embolism patients.
Speaker: I also want to thank you for your generosity with your time and expertise and hope to talk more with you in the future about vascular and cardiovascular-related topics.
Speaker: Sergio, I'd love to.
Speaker: Thank you very much.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
