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Pulmonary Embolism Update
17 Plays3 years ago
In this episode of the podcast, we will discuss the current management of Acute Pulmonary Embolism. Our guest is Dr. Belinda Rivera-Lebron, a pulmonary critical care physician who practices at the University of Pittsburgh Medical System. She is an Associate Professor of Medicine and is the Director of the UPMC Acute Pulmonary Embolus (PE) Program and the UPMC Chronic Thromboembolic Pulmonary Hypertension (CTEPH) Program. Dr. Rivera-Lebron’s areas of interest include pulmonary embolism and pulmonary hypertension.
Additional Resources
Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium.: https://pubmed.ncbi.nlm.nih.gov/31185730/
AHA Scientific Statement. Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: https://pubmed.ncbi.nlm.nih.gov/36688837/
PERT Consortium website: https://pertconsortium.org/
Books Mentioned in this Episode:
The Trusted Advisor. By David H. Meister, et al: bit.ly/3mq9Oap
Recommended
Transcript
Introduction to 'Critical Matters'
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now, your host, Dr. Sergio Zanotti.
Focus on Pulmonary Embolism Management
00:00:32
Speaker
In today's episode of the podcast, we will discuss current management of pulmonary embolism, PE.
00:00:38
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PE is a common disease in intensive care unit.
00:00:41
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However, PE is still underdiagnosed and often mismanaged.
Introduction to Dr. Rivera-LeBron
00:00:45
Speaker
Our guest today is Dr. Belinda Rivera-LeBron.
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Dr. Rivera-LeBron is a pulmonary critical care physician who practices in the University of Pittsburgh Medical System.
00:00:53
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She's an associate professor of medicine and is the director of
00:00:56
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for the UPMC Acute Pulmonary Embolist Program, and for the UPMC Chronic Thromoembolic Pulmonary Hypertension Program.
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Dr. Rivera-Lebron's areas of interest include pulmonary embolism and pulmonary hypertension.
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She's a recognized clinician, educator, and investigator.
00:01:12
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We're truly honored to have her today.
The Problem of Pulmonary Embolism Mortality
00:01:14
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Belinda, welcome to Critical Matters.
00:01:17
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Hi there.
00:01:17
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Thanks for having me.
00:01:19
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Excellent.
00:01:19
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So I remember reading many, many years ago that PE mortality was a problem of underdiagnosis and not of treatment.
00:01:29
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And I think this still holds some truth, but there's also so much more we can do for patients today.
00:01:35
Speaker
And I really wanted to cover those aspects of excellent care and pulmonary embolism with you today.
00:01:42
Speaker
Yes.
00:01:43
Speaker
And, you know, PE is still a serious problem.
00:01:47
Speaker
It's the third most common cardiovascular cause of death in the United States, believe it or not.
00:01:53
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It only follows like myocardial infarction and stroke.
00:01:57
Speaker
And it's definitely the most common preventable cause of death in hospitalizations.
00:02:03
Speaker
So it really is still a serious problem nowadays.
00:02:09
Speaker
There are about nine, almost a million cases of combined PEs and DVTs in the U.S. alone every year.
00:02:17
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And around 200, maybe 250,000 patients per year that die of a PE.
00:02:25
Speaker
So it's still a really relevant problem to talk about.
Innovations in PE Therapies and PERTs Role
00:02:30
Speaker
Absolutely, and something that we've all dealt with, obviously, in our clinical practice on a regular basis.
00:02:36
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On a daily basis, if you think about trying to prevent it, thinking about it, and then when we also have to treat it.
00:02:42
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But there's been some development over the last couple of years, I think.
00:02:47
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There's been renewed interest in pulmonary embolism with the advent of new therapies, and I thought this was a perfect topic for us to approach, and obviously, you being, I think, the perfect expert,
00:03:00
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share some of your knowledge with us.
00:03:02
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So what I would like to ask you is before we dive into the clinical management, if you could talk a little bit about pulmonary embolism response teams or PERT, and really what is a PERT first, and then I also wanted to hear a little bit about what the PERT consortium is.
00:03:20
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Yes.
00:03:21
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So the PERTs are PE response teams, and they've been developed maybe in the last five years or so, maybe a little longer now.
00:03:32
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They're a multidisciplinary team with expertise in PE management.
00:03:38
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And the idea is that you have multiple expertise
00:03:42
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experts in a single conversation that can help you with recommendations essentially immediately.
00:03:51
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And you don't have to call maybe your interventionalist and then get up a fall, then call again, the hematologist and get off the call and then call the surgeon and then get off the call.
00:04:05
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So you can get a centralized single activation system
00:04:09
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in which you get a rapid assessment of the patient comorbidities, you risk ratify the patient, and then you make recommendations about the treatment approach.
00:04:20
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And right then and there, since you have all the specialists in the single call, you can implement therapy right away.
00:04:27
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And it also serves as a form of research platform and streamlines a follow-up for the outpatient setting.
00:04:36
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So it's been, it's been a great for us in that, in that sense as well.
00:04:41
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And PERTs look differently in different institutions.
00:04:44
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So some,
00:04:45
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PERT, there's usually a PERT activation sort of head or leader, which may be pulmonary critical care, it may be interventional cardiology or maybe vascular surgery.
00:04:57
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Then you usually have a...
Structure and Function of PERTs
00:05:01
Speaker
uh, an interventionalist arm, uh, and that would be either interventional radiology or vascular surgery or, or interventional cardiology.
00:05:11
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Then there's the surgery arm, cardiothoracic surgery.
00:05:15
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Um, and, and then you have, uh, members of internal medicine or emergency medicine, since they're going to be the ones who are going to be activating or sort of making that initial phone call or, or paging system, depending on the hospital, different, uh,
00:05:29
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There's different ways on how to do that.
00:05:32
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But the PERT leader would get all the information and then they activate or involve the other members of the team as they're necessary.
00:05:41
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So not everyone is on the phone call at all times.
00:05:45
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And we can sort of talk a little bit about how we streamline as we get through the risk stratification scheme in our conversation.
00:05:55
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Absolutely.
00:05:56
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And obviously, like you mentioned over the last five years, and maybe if you take COVID out of the equation, it feels longer, right?
00:06:03
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But there's been a growth and interest in developing these teams.
00:06:08
Speaker
And I just find it fascinating that we'll talk about, like you said, more how to engage with the PERT and the patient.
00:06:15
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But it really is quite remarkable that innovation sometimes is really just about communicating, right?
00:06:23
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And having the right people to
00:06:25
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thinking about a problem to try to provide the greatest value for our patients.
00:06:29
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And with that in mind, I think that what you're trying to do is organize a response that is time sensitive, that's evidence based, and that's coordinated.
00:06:38
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And for patients with PE,
00:06:41
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I believe that it makes perfect sense.
00:06:43
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And I think that over time, we'll have a lot of data to support that, as in other diseases.
00:06:48
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Now, would it be fair to say, Belinda, that in many of these PERTs, the critical care physician, pulmonary critical care intensivist, they act almost like a quarterback?
00:06:57
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Right.
00:06:58
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So they're usually the PERT leaders, and they are going to be the ones who are going to be responsible for getting all the information from the referring, either referring physician in your own facility or taking the call from the transfer center if the patient's coming from the outside hospital to be transferred in.
00:07:18
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And so they're usually the ones who would be obtaining all this information and synthesizing it and then sort of discussing it with the rest of the team.
00:07:29
Speaker
Perfect.
00:07:30
Speaker
So before we go forward, I wanted you to tell us a little bit about the PERT consortium and what it is and
00:07:41
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how people can join if they have a PERT and are interested.
00:07:44
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But also, I want to just state that a lot of our discussion, at least from my perspective, was informed on a paper that you were the lead author from the PERT consortium, really trying to provide updated consensus practice and recommendations for pulmonary embolism.
00:08:03
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And obviously that for a clinician at the bedside is super useful.
00:08:06
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But I also know that a lot of our listeners are in the process of forming PERDS or have early PERDS and might want to know a little bit more about this.
00:08:15
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Absolutely.
00:08:16
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So the PERT Consortium is a group of institutions that have PERT teams in their own institution.
00:08:23
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And the reason why this came about is, I think it was back in 2014-15, when we've...
00:08:34
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We've started noticing that there's really ambiguity sometimes in clinical guidelines, right?
00:08:40
Speaker
So if you read the European guidelines, if you read the American guidelines, if you read chest guidelines, they're all going to be slightly similar depending on how much they put weight on each of the clinical trials that they review.
00:08:56
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And sometimes the guidelines are also not necessarily as up to date with the latest procedures.
00:09:04
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As you know, they do use randomized control trials and not necessarily retrospective reviews, et cetera.
00:09:11
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So when we've noticed that there was this variation and ambiguity in clinical guidelines, we wanted to essentially get together and get expert consensus.
00:09:23
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And also by doing that, then we'd be able to somehow and in some way be able to standardize all aspects of PE care from diagnosis to risk ratification to treatment and then ultimately follow-up care.
00:09:41
Speaker
So it really has been...
00:09:45
Speaker
a monumental effort in getting together, and it's a unique organization in which there are, it's not just pulmonary critical care, right?
00:09:55
Speaker
It's going to be heritage in the members, and that's great because we just learn from each other.
00:10:01
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so much and you know we all bring things from a different perspective.
00:10:06
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So the way to join is through the PERT consortium's website and for hospitals or institutions that have, that are
PERT Consortium's Contribution
00:10:17
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in starting and earlier phases, there's actually what they've created like a PERT toolbox
00:10:22
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So they'll help you how to get this from the ground up.
00:10:29
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And you don't have to reinvent the wheel.
00:10:31
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This has already been done in multiple other places, so you don't have to do it by yourself and without any help.
00:10:37
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So I think that they offer all these, and these are free.
00:10:42
Speaker
You don't have to pay to become a member.
00:10:47
Speaker
And actually coming up, there's going to be a PERT accreditation.
00:10:51
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So PE accreditation, it's going to become the PERT consortium is going to create a PERT like Centers of Excellence.
00:11:01
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And that's something that's going to be coming into Verizon in the next year or so.
00:11:06
Speaker
And it's going to, again, streamline efforts into making sure
00:11:11
Speaker
different institutions are going to provide similar care across the board.
00:11:16
Speaker
So if you go, you know, somewhere in the hospital here, you'll get the same care that you would in another place.
00:11:21
Speaker
So I think that that's going to drive the, you know, this disease sort of forward.
00:11:27
Speaker
Excellent.
00:11:27
Speaker
And we'll definitely not only link the consensus guidelines, but also the website so people can take a look.
00:11:35
Speaker
And like you mentioned, there's a lot of very useful information there.
00:11:39
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Now, before we move on to the clinical topic, specifically management of PE, I think there's maybe a misconception out in the community that PERTs are just reserved for large academic centers.
00:11:55
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I think that there's a lot of hospitals that would benefit from organizing
PERTs in Small Hospitals
00:11:59
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their PE care.
00:12:01
Speaker
Any comments on who should have a PERT?
00:12:04
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Absolutely.
00:12:05
Speaker
And I think this is a very important topic.
00:12:07
Speaker
And we've definitely seen that the PERTs are now outside of academic institutions and PERTs work.
00:12:18
Speaker
You know, the outcomes are good regardless of wherever you are.
00:12:22
Speaker
So you can be at a smaller hospital and it would work equally as well.
00:12:27
Speaker
And you don't need to have all the services available at your institution.
00:12:31
Speaker
You can partner with a PERT, you know, at another hospital.
00:12:34
Speaker
institution that you would normally send your patients to, and that also will help streamline care as well.
00:12:41
Speaker
So it can be done and it doesn't need to be in a big academic center.
00:12:46
Speaker
Absolutely.
00:12:48
Speaker
Excellent.
00:12:49
Speaker
So let's talk about PE.
00:12:51
Speaker
And I think we would start really with a diagnosis.
Diagnostic Tools for PE: Pre-Test Probability and AI
00:12:55
Speaker
And I know that there's historically been talked about symptoms, signs, EKG and x-ray findings.
00:13:02
Speaker
And
00:13:04
Speaker
some classical, but often very nonspecific.
00:13:07
Speaker
So really just if you can give us your perspective on how you think about diagnosis at the bedside.
00:13:14
Speaker
I think PE is all about pre-test probability because, as you know, as you mentioned, the symptoms are really nonspecific, right?
00:13:20
Speaker
So any of these symptoms that a patient with PE will present with can be any other cardiopulmonary disease as well.
00:13:29
Speaker
So shortness of breath being the most common, but chest pain is also common.
00:13:35
Speaker
And it could be.
00:13:36
Speaker
Then some of the things that are a little bit more unique would be pre-test.
00:13:41
Speaker
potentially syncope or if they have unilateral leg swelling, then that kind of, you know, leads you to more of a DVT and then it, you know, increases your pretest probability as well.
00:13:51
Speaker
Um, so then, you know, using well score wealth criteria, um, is probably the easiest way to go around it.
00:13:58
Speaker
If you're, if you're, uh,
00:13:59
Speaker
if you're in an emergency department and someone comes in with new symptoms, and then you sort of plug it in and you can use any of the calculators that are out there and then that kind of tells you, you know, is the PE likely or unlikely?
00:14:11
Speaker
And if the PE is likely, then you go for the CT angiogram, gold standard.
00:14:15
Speaker
And if it's unlikely, then you can, you know, use that with a D-dimer, perhaps decide if you need to move up the ladder and do get the CT or can you just like rule it out effectively if the D-dimer is negative.
00:14:28
Speaker
One word about the diagnosis, which is a new thing that's coming out and that probably will be here to stay, is the artificial intelligence in PE diagnosis.
00:14:40
Speaker
I don't know if you've heard any about this.
00:14:42
Speaker
Have you heard anything about this, like AI and PE?
00:14:44
Speaker
Well, I haven't heard about it in PE.
00:14:46
Speaker
I just know that, what is it called, GPT chat passed the USMLE boards.
00:14:51
Speaker
Yeah.
00:14:54
Speaker
Well, so there's this new thing.
00:14:57
Speaker
We still, our hospital doesn't have it, but multiple hospitals have it, and we're sort of in the works of getting this done.
00:15:03
Speaker
But we've used the same technology as most centers have now for stroke.
00:15:10
Speaker
So essentially the patient can...
00:15:14
Speaker
can get a scan.
00:15:15
Speaker
The scan is uploaded into this cloud and, and, and the, the, the computer system has an algorithm that can tell you whether or not there is a PE present or absent in essentially 60 seconds.
00:15:28
Speaker
Wow.
00:15:29
Speaker
So,
00:15:30
Speaker
That goes through an app, and the app gives you a notification to either the ordering provider or the PE team or whoever, I guess, you want to be notified about this PE.
00:15:41
Speaker
But it's really incredible, and they've tested, you know,
00:15:48
Speaker
sensitivity, specificity, all those things, and they're really good and close to what a chest radiologist would be, which is kind of unheard of, right?
00:15:58
Speaker
So it's getting a read back in 60 seconds within the study being, you know, run.
00:16:05
Speaker
So that is kind of something that's coming, and we'll see
00:16:09
Speaker
how this sort of, again, moves the field forward.
00:16:13
Speaker
But we're in the works of trying to get something like this implemented.
00:16:17
Speaker
And there's like three different platforms that are available that could be, you know, linked to your hospital sort of depending on what system do you use.
00:16:28
Speaker
It could just be linked and it's all like sort of HIPAA protected and protected.
00:16:32
Speaker
but it really decreases like reading time significantly because the radiologist also gets notification and they can sort of prioritize, okay, you know, I will read out the abnormal scans first, right?
00:16:43
Speaker
The positive scans and then leave the other ones.
00:16:46
Speaker
And I think on a serious note, Belinda, right?
00:16:48
Speaker
A lot of people are reading about AI and ask the question, are they going to replace everything we do?
00:16:53
Speaker
But I think that really the,
00:16:55
Speaker
The next real frontier for us in medicine is clinical care augmented by AI, right?
00:17:02
Speaker
You still need, obviously, the clinicians to make decisions.
00:17:05
Speaker
But like you said, in terms of prioritizing and accelerating the implementation of time-sensitive interventions, clearly this is one perfect example of that.
00:17:17
Speaker
Now, you talked about, obviously, the risk stratification or pretest probability when the D-dimer can be helpful, which I think is something important for our ED and hospitalist colleagues who might be seeing the patients first.
Alternative Diagnostic Methods: VQ Scans and ECHOs
00:17:31
Speaker
You also talked about kind of what we consider to be the gold standard now, which is the CTA,
00:17:36
Speaker
with or without the AI augmentation to accelerate readings.
00:17:41
Speaker
One of the things that often pops up again and that I think was much more present in the older days, like when I was training, right, is the use of VQ scans.
00:17:52
Speaker
Can you just give us a little bit of your perspective on when and how does the VQ scan become useful?
00:18:01
Speaker
For the acute setting, I think it helps with...
00:18:07
Speaker
Perhaps situations where we have like a contrast allergy and maybe you don't want to wait until you give the patient the pre-meds or if they have the true acute renal failure or chronic renal failure that they cannot be dialyzed.
00:18:25
Speaker
I think that those would be the two most common scenarios.
00:18:29
Speaker
Now, in chronic settings, which I know we're not talking about today, but especially for CTAP, chronic thrombotic pulmonary hypertension, it's definitely gold standard for diagnostic strategy just because the chronic clots are much more peripheral and smaller in nature, and they could be missed in a CT angiogram.
00:18:51
Speaker
Perfect.
00:18:52
Speaker
And just to finish up on our diagnosis discussion, any comments on the role of echocardiography and also when and how do you incorporate lower extremity Dopplers?
00:19:06
Speaker
Yes, so ECHOs, I think for anything that is intermediate or higher, so some massive or massive, so intermediate or high risks, they're complementary because they are going to give you information on the RV, right?
00:19:21
Speaker
And the RV essentially is predictor of outcomes.
00:19:25
Speaker
So not necessarily the clot burden, right?
00:19:28
Speaker
So the CT scan gives you thrombus location and amount.
00:19:37
Speaker
And it may also give you a good perspective on the dilation of the right ventricle, but the echocardiogram is better at it.
00:19:48
Speaker
So for patients who have an intermediate or high risk, it's definitely...
00:19:55
Speaker
necessary to know if the RV is dilated and that's going to play a role into decision making for treatment.
00:20:04
Speaker
So I think for those patients are definitely necessary and also for following up patients in the outpatient setting.
00:20:12
Speaker
So once they're over the acute
00:20:15
Speaker
then you would want to know if this RV gone back to normal.
00:20:19
Speaker
Have they recovered from that?
00:20:21
Speaker
And that also predicts whether or not they'll have chronic complications from their PE.
00:20:28
Speaker
In terms of the lower extremity Dopplers, I think that I find them helpful when perhaps I think the patient is
00:20:38
Speaker
may not tolerate anticoagulation, and in that scenario, you are considering a filter.
00:20:45
Speaker
And whether or not they're...
00:20:49
Speaker
And the other scenario and may help would be if there's presence of a lot of clot burden and you already have it submassive or intermediate or massive, if you have proximal DVT that may be mobile, that also is a risk for decompensation further if that sort of DVT then gets dislodged.
00:21:12
Speaker
So I think it would be helpful in those scenarios.
00:21:17
Speaker
Perfect.
00:21:18
Speaker
So the next topic that I wanted to dive in a little bit, which I think is perhaps a topic that
PE Risk Categories and Treatment Impact
00:21:25
Speaker
is not as well applied at the bedside, yet I think has tremendous value in helping us move forward in our care is risk stratification.
00:21:36
Speaker
And really, really understanding, I mean, and what low, intermediate, and then within intermediate, what's intermediate, low, intermediate, high, and high-risk PE means.
00:21:48
Speaker
Because if you really read the literature, Belinda, it would seem that these actually have direct implications on our therapeutic conduct and understanding.
00:21:58
Speaker
My impression is that people kind of half-heartedly classify these patients, but there's better ways of doing it and being more precise in a way that we both would look at the patient and agree, yeah, this is a high risk or intermediate risk.
00:22:14
Speaker
Right.
00:22:15
Speaker
I think that I would like to start by saying we've sort of gone away, as you correctly are identifying, we've gone away from this massive and submassive sort of way of calling clot burden because, again, it goes more along the lines of thrombus burden as opposed to...
00:22:38
Speaker
the effect that it may have on its morbidity and mortality.
00:22:43
Speaker
So that's why we moved away from that sort of categories, and now we call them low, intermediate, and high risk.
00:22:49
Speaker
But they're just replacing what that old sort of nomenclature was.
00:22:54
Speaker
So the low risks are the most common.
00:22:56
Speaker
You know, 50%, 60% of the patients are going to have a low-risk PE.
00:23:01
Speaker
Those are going to be totally hemodynamically stable.
00:23:04
Speaker
They are...
00:23:07
Speaker
Having normal biomarkers, so troponin, BMP are going to be negative.
00:23:13
Speaker
And they also have this thing called the PE score index, so the PESI score, normal.
00:23:20
Speaker
And the PESI score is another sort of level in a way to classify patients into poor outcomes.
00:23:31
Speaker
So it includes characteristics of patients that you think they're going to do poorly.
00:23:37
Speaker
For older, if they have a history of cancer or pre-existing cardiopulmonary disease, if they're tachycardic, hypotensive, they need oxygen.
00:23:47
Speaker
If any of those are present, then automatically they're going to have
00:23:51
Speaker
an abnormal PESI score or a PESI score one or more in the simplified version.
00:23:56
Speaker
So this low risk category of PEs are going to have a normal PESI, meaning they're going to be zero.
00:24:02
Speaker
They're not going to have any of these characteristics that are going to be abnormal.
00:24:08
Speaker
Then following that, then we have the intermediate category.
00:24:13
Speaker
And the intermediate in the European guidelines now for a few years, five, six years, they've changed the way that they divided the intermediate into intermediate low and intermediate high.
00:24:27
Speaker
And the difference between the two is that the intermediate low, they're still both of them are going to be hemodynamically stable.
00:24:34
Speaker
So their systolic blood pressure is going to be 90 or more.
00:24:39
Speaker
But they are going to have for the intermediate low, it's either RV dilation dysfunction on CT or imaging.
00:24:49
Speaker
So it could be on CT or echo or the cardiac biomarker, which again is BNP for pronin.
00:24:56
Speaker
can be abnormal.
00:24:57
Speaker
So the intermediate low is going to have one of those two abnormal and the intermediate high are going to have both abnormal.
00:25:04
Speaker
So both presence of RB strain or RV dilation dysfunction and the biomarker that is abnormal.
00:25:12
Speaker
And the reason why they did that is because when they looked into outcomes, the patients who have obviously both markers, so both the dilation on imaging and the biomarker abnormal, they have worse outcomes.
00:25:27
Speaker
The mortality can go from maybe around 2% to 5% to 5% to 20%.
00:25:30
Speaker
So it could be a significant jump.
00:25:37
Speaker
for that patient and that might be a patient that you definitely want to think about, not necessarily, but think about whether or not they need to have something additional to anticoagulation to be able to overcome this sort of acute illness time period.
00:25:57
Speaker
And then ultimately, then you have the high risks, so used to be massives, and those are going to be hemodynamically unstable.
00:26:05
Speaker
So they have a systolic blood pressure of less than 90, or obviously they're on a presser, or they have gone into cardiac arrest.
00:26:12
Speaker
Ultimately, that would be what you want to avoid, but they could still present that way.
00:26:17
Speaker
And in that patient, it really doesn't matter how the RV or the biomarkers work.
00:26:21
Speaker
are because you already sort of overcome the stratification scheme by being hypotensive.
00:26:27
Speaker
So if you're hypotensive, then you're sort of in that highest risk of decompensation and...
00:26:36
Speaker
So that's the classification in a nutshell.
00:26:40
Speaker
And the most common, again, the low risk following by the intermediate risk, which are still a good amount, about 40%, and then 5% to 10% are going to be in the high risk category.
00:26:53
Speaker
Perfect.
00:26:53
Speaker
So a couple more questions to clarify on this topic.
00:26:59
Speaker
First is oxygenation or degree of hypoxemia.
00:27:04
Speaker
Does that play into this at all?
00:27:10
Speaker
There's a textbook answer and then there's the clinical answer, right?
00:27:15
Speaker
Yeah, the bedside answer.
00:27:16
Speaker
And I think
00:27:17
Speaker
So if you look at any of the risk ratification schemes, they don't include oxygenation necessarily as a separate single category, such as the hypotension is sort of separate and has its own sort of category.
00:27:33
Speaker
However, the oxygenation is part of the PESI score.
00:27:37
Speaker
So whether or not you need oxygen, that will give you sort of that point in the PESI score.
00:27:47
Speaker
And that will just, what it tells you is that it's just you're at increased risk of morbidity.
00:27:54
Speaker
And for every single one of those, if you have a point or more, then you automatically go from...
00:28:01
Speaker
1% mortality to around the 10% non-mortality, I'm sorry, morbidity to around a 10% morbidity.
00:28:07
Speaker
So it gives you a perspective of where things are.
00:28:14
Speaker
Now, it doesn't discriminate between an oxygenation of requiring two liters versus 10, 15 liters, right?
00:28:19
Speaker
And we know in the critical care setting, you know, you think about those two patients completely differently.
00:28:25
Speaker
Perfect, yeah.
00:28:26
Speaker
And you're right, I mean, in the PESI score, you include also things like respiratory rate and saturation below 90.
00:28:34
Speaker
So those would capture that in that score.
00:28:37
Speaker
And that's why I think it's important.
00:28:39
Speaker
to really apply this, and it takes you, I mean, it doesn't take too long to get objective data that can be very helpful, I think, on both extremes, but also in terms of guiding therapeutic conduct, right?
00:28:51
Speaker
I mean, because if you're truly low risk, patients can sometimes be treated and sent home, right?
00:28:57
Speaker
Or admitted to the floor.
00:28:58
Speaker
But everybody who's intermediate risk and above,
00:29:01
Speaker
requires probably a little bit more attention.
00:29:03
Speaker
And the second thing I wanted to point out, and I wanted your thoughts, Belinda, is that I often get called by colleagues outside of the ICU because there's bilateral PE, or there's a lot of clot on the CAT scan.
Focus on Hemodynamic Impact in PE Management
00:29:18
Speaker
And really what we're saying is that, yes, but that's really not what I care about, right?
00:29:24
Speaker
Let's look objectively at what is the impact of that
00:29:28
Speaker
clot burden on hemodynamics and what are the risk factors of our patient and that will determine where that patient should go and how they should be treated
00:29:37
Speaker
I mean, we see all the time sort of young patients, right?
00:29:41
Speaker
19-year-olds, obviously no comorbidities, and they could have a sad OPE with a lot of proximal clot burden.
00:29:48
Speaker
The RV is completely normal.
00:29:50
Speaker
That patient, the anacoagulation alone, right?
00:29:53
Speaker
So you don't really do anything because we know that the risk of decompensation is low if the RV is normal.
00:30:00
Speaker
So as opposed to perhaps an elderly patient that has, may not have a sad OPE, but may have sort of proximal clot burden and they have, you know, coronary disease, COPD, some other diastolic dysfunction.
00:30:16
Speaker
And then they end up with a very large and enlarged right ventricle and a lot of dysfunction from a much smaller clot burden amount.
00:30:27
Speaker
So you're absolutely right.
00:30:29
Speaker
And the last question I have in this topic of risk certification is regarding the simplified PESI.
00:30:37
Speaker
Do you find that useful at the bedside or it's just not discriminatory enough for you to really work with your part?
00:30:44
Speaker
I think that where it's helpful is...
00:30:49
Speaker
Once you've decided, okay, so the patient has RV dysfunction and they have a positotroponin, right?
00:30:57
Speaker
But they are only on two liters and they're not, but then, and they, they may not be tachycardic.
00:31:04
Speaker
Their heart rate might be 80 and their blood pressure is 140 over 80.
00:31:08
Speaker
That patient may just be observed on anticoagulation alone.
00:31:12
Speaker
And, and the, the,
00:31:13
Speaker
The key thing is observed, right?
00:31:14
Speaker
So then you just, you know about the patient, you're aware of them, but you don't need to act immediately.
00:31:19
Speaker
You start on a coagulation and then you follow.
00:31:22
Speaker
Trend over time.
00:31:23
Speaker
Let's see what the vitals will do over time.
00:31:26
Speaker
So, and that's where the PESI is going to help you because the PESI includes those vitals.
00:31:33
Speaker
as opposed to someone who same RV dysfunction, same troponin that's elevated, but they've gone from four liters in the ER to perhaps six, seven liters once they get to the ICU.
00:31:49
Speaker
Their heart rate started at 120 and it really hasn't budged.
00:31:54
Speaker
It's still at 120.
00:31:56
Speaker
their blood pressure is still stable, but you just don't like where the trend is going.
00:32:00
Speaker
So I think that that's where the PESI is helpful because it has the characteristics that you need to follow along over time.
00:32:10
Speaker
But I think it's more useful to know how those –
00:32:14
Speaker
vitals change over time than a single static view of these numbers, because that's going to tell you where is the risk going into and how likely are they to decompensate or not.
00:32:28
Speaker
Perfect.
00:32:29
Speaker
So we're going to move on to talk about actual therapy, but just to remind our viewers and
00:32:36
Speaker
And I'll have links to these in the show notes.
00:32:39
Speaker
So PESI is Pulmonary Embolism Severity Index.
00:32:42
Speaker
And really, it's a set of variables.
00:32:44
Speaker
It goes from 1 to 125, to more than 125.
00:32:47
Speaker
It includes age, male sex, history of cancer, heart failure,
00:32:52
Speaker
chronic lung disease, a pulse rate above 110, blood pressure below 100, respiratory rate above 30, body temperature below 36, altered mental status, SATs below 90.
00:33:04
Speaker
And based on that, you add all the points, and then it gives you below 65 is very low.
00:33:08
Speaker
Below 85 is low risk.
00:33:08
Speaker
Below 86 to 105 is intermediate risk.
00:33:09
Speaker
And then above 106 is high risk.
00:33:18
Speaker
So you can do that very quickly.
00:33:20
Speaker
I'm sure there's an app for that.
00:33:21
Speaker
And it can really quickly classify your patient.
00:33:24
Speaker
And like you said, you can follow this over time and also give you an idea if the patient is deteriorating.
00:33:30
Speaker
And like with any of these calculators, there's a simplified version and there's a long version.
00:33:36
Speaker
And they're equally great, both of them.
00:33:40
Speaker
And they both perform well when you compare.
00:33:44
Speaker
And the simplified is just simpler.
00:33:46
Speaker
And you don't have to go through those ranges as opposed to the longer version.
00:33:51
Speaker
It's either zero or one.
00:33:52
Speaker
Yeah.
00:33:53
Speaker
So either the simplified would, I think, includes the age, history of cancer, heart failure, chronic lung disease, pulse rate over 110, systolic pressure below 100, and SAT below 90.
00:34:05
Speaker
And like you said, you get one point for any of those, and one point or more already puts you in the high risk.
00:34:12
Speaker
So that's something that you can very quickly, literally in seconds, figure out, right?
00:34:17
Speaker
and determines that.
00:34:18
Speaker
So we'll link to all of these in the show notes.
00:34:21
Speaker
But now that we've risk stratified our patient, I would say that in our world, Belinda, we're interested in intermediate risk and above, right?
00:34:29
Speaker
If you're low risk, you have objective data saying that probably their risk of deterioration is very low.
00:34:36
Speaker
They should be treated and they don't need
Anticoagulation Strategies for PE
00:34:38
Speaker
to be in the ICU.
00:34:38
Speaker
And in some cases, they might even be discharged, but a lot of them will be admitted to the hospital.
00:34:43
Speaker
So those that are intermediate risk or above will come to us.
00:34:47
Speaker
So we start treatment, obviously, with anticoagulation, and we can just start there and just give us your thoughts on anticoagulation and what it means for the intermediate and above-risk patients.
00:35:01
Speaker
I think the first thing to obviously do is anticoagulation and acknowledge that heparin takes time for it to work.
00:35:09
Speaker
And I know sometimes we in the ICU setting tend to worry about the complications, but this is a scenario in which actually you have to worry about the anticoagulation not being as effective.
00:35:22
Speaker
So,
00:35:23
Speaker
For most of the recent guidelines, they've acknowledged that low molecular weight heparin is preferred over unfractionated heparin.
00:35:31
Speaker
And this is the case even if you think the patient may need to be on, may need to get additional therapy, such as the advanced therapies.
00:35:40
Speaker
In most institutions, the interventionalists would be okay with them being started on low molecular weight heparin.
00:35:49
Speaker
And also where a situation where low molecular weight heparin is better is if they're going to be transferred from another hospital, then that way you just tell them, okay, give them a weight-based single dose, and then we'll worry about it when we get here.
00:36:03
Speaker
You don't have to titrate and the burden of dealing with the heparin drip that we know that, you know.
00:36:13
Speaker
And the reason why we've done that is because even in our own institution, we've looked into our data from our ICU, and we've seen that it takes, even if you order the correct heparin nomogram, it can take more than 24 hours to a patient to become therapeutic.
00:36:34
Speaker
And that, you don't want that, right?
00:36:37
Speaker
It's sort of like a false reassurance when you think, oh, the patient's on heparin drip, but their, you know, 10A or PTT, depending on what you use, is sub-therapeutic.
00:36:45
Speaker
It's like they're not on anything, as opposed to just, you know, giving them a dose of low-molecular weight heparin.
00:36:52
Speaker
So unless you have a contraindication, you know, obesity or acute renal failure, then we prefer to use the low-molecular weight heparin over unfractionated heparin in most scenarios.
00:37:06
Speaker
So that's, I guess, on anticoagulation.
00:37:07
Speaker
Start anticoagulation on everyone, again, and even if they're even a candidate for any of the advanced therapies.
00:37:14
Speaker
And then in the ICU, then we have to think about, you know, things like thrombolysis.
00:37:19
Speaker
And as you know, thrombolysis comes in different flavors, sort of systemically, or catheter-directed.
00:37:26
Speaker
And sort of depending on the risk ratification, that's when we start thinking about these sort of advanced therapies.
Systemic Thrombolysis for High-risk PE
00:37:34
Speaker
I think it's uniformly and probably across the board accepted that systemic thrombolysis is reserved for patients who have a high-risk PE who have low bleeding risk.
00:37:45
Speaker
And those are primarily the patients who are going to treat with systemic thrombolysis.
00:37:52
Speaker
FDA approved dose for the United States, it's a TPA, 100 milligrams over two hours.
00:37:59
Speaker
If you are in a code or, you know, a cardiac arrest condition, then you can give a bolus of 50.
00:38:05
Speaker
I guess if the patient makes it, you can decide if you give the other 50 later on.
00:38:11
Speaker
But I think that's for systemic thrombolysis.
00:38:14
Speaker
the preferred.
00:38:16
Speaker
And the reason why is we know they just bleed, right?
00:38:20
Speaker
So the risk of bleeding is higher.
00:38:22
Speaker
So then you cannot justify giving systemic thrombolysis to other patients.
00:38:26
Speaker
Go ahead.
00:38:27
Speaker
Perfect.
00:38:27
Speaker
Sorry.
00:38:27
Speaker
So I wanted to ask you one anticoagulation question and then follow up that with a systemic thrombolytic question.
00:38:35
Speaker
So in terms of anticoagulation, and obviously you were explaining the importance of getting therapeutic like
00:38:42
Speaker
now, right?
00:38:43
Speaker
I mean, not in 24 hours and the advantages of low molecular weight heparin.
00:38:47
Speaker
But just could you comment a little bit more, Belinda?
00:38:50
Speaker
I think that a very common dogma, right, which is not probably based on trials, but I think on common belief is that for patients who might be requiring additional therapies, right, or that are in the ICU, the advantage of a unfractionated heparin drip is
00:39:09
Speaker
is that you can stop it and have a shorter half-life.
00:39:14
Speaker
Does that really play into the equation?
00:39:16
Speaker
Or like you said, in most of your experience and what's been shown is that probably because of the need for anticoagulation in most of our patients, low-molecular weight heparin, give the right dose and go from there is the way to go.
00:39:30
Speaker
I mean, what we've seen is that there really has not been an increased risk of bleeding when you use LOMO-array heparin compared to unfractionated heparin if they go for any of the advanced procedures.
00:39:44
Speaker
So the tradeoff is, like you mentioned, the faster time for therapeutic treatment.
00:39:50
Speaker
Um, and it, they're, like you said, it's, it's a sort of like a misconception and, and, and people get very worried about it.
00:39:58
Speaker
Um, but the reality is that the risk of bleeding is not higher when you use, um, the low molecular weight heparin.
00:40:04
Speaker
So there really should not be a reason why that should stop you if you are considering advanced therapies.
00:40:11
Speaker
Yeah.
00:40:11
Speaker
Absolutely.
00:40:12
Speaker
And I guess the other point that I would make for our listeners and definitely want to hear your comments is that with antichrylation, especially because of the time-sensitive nature, that even with high suspicion, it should be initiated unless the patient has clear contraindications.
00:40:27
Speaker
And sometimes we shouldn't be delaying a definitive diagnosis when we have a high suspicion and the patient is not at high risk for bleeding with the antichrylation portion.
00:40:37
Speaker
Correct.
00:40:38
Speaker
And that's what the guidelines say.
00:40:39
Speaker
So let's say worst case scenario, your CT scans down or the patients like say the weight is above the limit for then you should start an ecoagulation even before you have a confirmatory diagnostic test.
00:40:54
Speaker
If they're bleeding risk is low and the clinical suspicion is high.
00:40:59
Speaker
Perfect.
00:41:00
Speaker
Now, the other question I had regarding thrombolysis is there's obviously the traditional absolute contraindications for thrombolysis, but there's also a list of relative contraindications.
Reduced-dose Thrombolysis Considerations
00:41:15
Speaker
In those patients who are high risk, who might have post-cardic arrest or hypotensive on pressors, who might have some of these relative contraindications, a little bit older, very low body weight, have abnormal platelets, might be elevated INR, hypertensive, recent surgeries, etc.
00:41:36
Speaker
Would there be any value in considering the half dose or the lower dose of 15 mg that you mentioned?
00:41:43
Speaker
It is, it's safer, using half doses safer, but it hasn't proven to be as equally effective.
00:41:50
Speaker
So that's why still the FDA recommends using the 100 milligrams.
00:41:54
Speaker
But in clinical practice, I mean, you have to use your judgment and know what's your, you know, what are your other options in that scenario.
00:42:01
Speaker
So if you have any other contraindications, even if it's a
00:42:05
Speaker
relative contraindication, how is this the patient, you know, like stably unstable or is the unstably unstable?
00:42:12
Speaker
Right.
00:42:14
Speaker
And so, so are they, are they high risk, meaning they're hypotensive, but they're on a little bit of norepinephrine and they've been fine.
00:42:24
Speaker
They're having, you know,
00:42:25
Speaker
they've stayed fine since the emergency room or for some time, so you don't need to act immediately, then maybe that patient you can talk to your interventionalist and they can do a catheter, mechanical suction procedure, which does not require any TPA or thermolysis.
00:42:48
Speaker
But if the patient is unstably unstable, meaning you're adding pressers, increasing dosing frequently or rapidly, then you don't have time to wait.
00:43:02
Speaker
You don't have time to move them to...
00:43:05
Speaker
the cath lab or the OR or wherever to get a procedure and they may not even be stable enough to move so then your alternative is a spiral of death, RV failure, cardiac arrest so you just have to weigh in what's the risk and benefit and
00:43:21
Speaker
in each of those scenarios.
00:43:23
Speaker
And that's why these exactly are the situations in which the PERT teams are so useful because you're not making that decision by yourself.
00:43:32
Speaker
So you are weighing in different options
00:43:37
Speaker
And everyone is weighing in and giving recommendations as a unified front to the provider who is going to be actually responsible for the patient.
00:43:48
Speaker
And then that will be able to take some of the load off, right?
00:43:53
Speaker
So you feel better when you're making decisions together about that decision.
00:43:59
Speaker
Absolutely.
00:44:00
Speaker
So we talked about systemic thrombolysis.
00:44:03
Speaker
You also mentioned catheter-directed thrombolytics.
00:44:06
Speaker
And can we talk a little bit about how you use that in your practice and what the guidelines recommend in terms of approaching patients?
00:44:14
Speaker
Yeah, definitely.
00:44:16
Speaker
So the catheter-directed procedures have sort of become – have increased sort of popularity and gained momentum in the last, you know, three or four years or so.
00:44:28
Speaker
And there's – so for catheter –
00:44:30
Speaker
procedures, there's catheter-directed lysis, in which you put in the TPA through a catheter that it may be a multi-hole sort of catheter, or it may be one of the branded ones, Ecosys, the branded ones that uses an ultrasound to penetrate the medication into the clot.
00:44:53
Speaker
Or it can be catheter thrombectomy, in which case you don't use any
00:44:59
Speaker
TPA, so there's just the action of removing some of the clot burden with different types of catheter.
00:45:09
Speaker
And it probably used to be when catheter procedure started to be used earlier, like four years ago, five years ago, that the catheter lysis was the most popular procedure.
00:45:23
Speaker
But nowadays, the pendulum has sort of shifted, and I think most of the procedures that are done by catheter are done without TPA.
00:45:32
Speaker
So they're just suction thrombectomy or just catheter thrombectomy, as we call them.
00:45:39
Speaker
And this is the, but both of them have really good outcomes in terms of their risk of bleeding is quite low, much lower than if you would give systemic TPA.
00:45:55
Speaker
Actually, if you use suction thrombectomy, the risk of bleeding can be close to zero as there's, you know, just the bleeding from, I guess, using the anticoagulation alone.
00:46:05
Speaker
It's similar in that range.
00:46:09
Speaker
But catheter TPA, the claim to fame is that it reduces quickly the RV dysfunction that you may have from these intermediate risks or in high risk as well.
00:46:27
Speaker
And it can reduce the...
00:46:30
Speaker
or normalize the RV rapidly.
00:46:32
Speaker
So within 24 hours, you may have a complete normalization of the RV, as opposed to 90 days or three months, which we would see in patients that just are treated with anticoagulation alone.
00:46:49
Speaker
So that's when those patients that you don't think can survive that initial period, that's when you need to consider using any of these advanced catheter-directed techniques because they sort of get them through that hump in the first day, 24 to 48 hours.
00:47:08
Speaker
Perfect.
00:47:09
Speaker
And in terms of choosing, so really, like you said, this is the great value of a PERP team discussing appropriate therapies.
Catheter-based Interventions for PE
00:47:19
Speaker
But in places that have well-established interventional programs through cardiology, interventional radiology, vascular surgery, whatever it would be, obviously the local expertise is going to be also very important in which one you use.
00:47:34
Speaker
But this is mostly reserved, I would imagine, or I understood for the intermediate high risk, right?
00:47:42
Speaker
So before they have hypotension, shock, and cardiac arrest, these are the patients kind of in the middle who have RV dysfunction, but not maybe in shock, that you would consider these catheter-directed therapies.
00:47:54
Speaker
Right.
00:47:55
Speaker
So you sort of like the entry point that you need to be intermediate high for the most part.
00:48:01
Speaker
So what that looks like is, again, a patient who has RV dysfunction on imaging, plus the biomarker that is abnormal.
00:48:10
Speaker
And then what we use in our center is, again, the vitals and the overall sort of trajectory of the patient.
00:48:16
Speaker
So if the, again, if the patient is
00:48:19
Speaker
even if they have intermediate high-risk PE, but they're on room air, one liter, two liters, they're not tachycardic,
00:48:28
Speaker
and they look well, then that patient is treated with anticoagulation alone.
00:48:31
Speaker
But if they have intermediate high risk and then they are tachycardic and that doesn't resolve and their blood pressure maybe was 140 and now it's 120 or 110, so we see sort of the trajectory.
00:48:44
Speaker
They're still not in the high risk, but they're just sort of moving where you don't like them or their oxygen is increasing.
00:48:53
Speaker
or they have syncope, you know, that's another sort of marker of just like a blocked cardiac output, I guess, in a way, then those would be the ones that you consider any of the catheter-directed techniques, although it can be used in high risks as well.
00:49:09
Speaker
Like I mentioned, if you have a high-risk patient that is sort of stable, you know, they're hypotensive, but they're on low-dose procedures,
00:49:16
Speaker
and you can move them and you have enough time to get all the team together.
00:49:21
Speaker
That certainly could be used.
00:49:23
Speaker
And actually there's a recent registry using one of the catheters that show good outcomes even in patients that have high-risk PEs that these procedures were used.
00:49:36
Speaker
Excellent.
00:49:36
Speaker
So a couple more questions just to dive a little bit deeper, Belinda.
00:49:41
Speaker
Is there a difference in outcomes?
00:49:44
Speaker
Or before actually we talk about differences, when we talk about improved outcomes, you mentioned already, but I just want to reemphasize, it's really about RV function, right, on the short term.
00:49:56
Speaker
It's that R to right to left ventricular ratio and the RV function itself measured by pulmonary pressures.
00:50:04
Speaker
that really improves quickly in patients who have catheter-directed therapies.
00:50:10
Speaker
We really don't have data on mortality, and that's been a problem, I think, in a lot of PD treatment just because of the numbers, right?
00:50:19
Speaker
No prospective data on mortality.
00:50:21
Speaker
There is retrospective data on mortality.
00:50:24
Speaker
We've actually looked at in our center for catheter-directed lysis in mortality, and when you look at catheter-directed lysis versus anticoagulation in patients that have intermediate risk, we did show in our
00:50:42
Speaker
in our institutions that we have a decrease in their mortality when you match sort of the patients.
00:50:50
Speaker
We actually match them by PESI score, so, you know, using characteristics at baseline.
00:50:57
Speaker
But that has not been replicated in other trials.
00:51:00
Speaker
So some trials have been positives, meaning they have good outcomes, a decrease in mortality, and some have no change in mortality.
00:51:09
Speaker
So there's really...
00:51:11
Speaker
No consensus yet, and there isn't a prospective trial that it's been shown.
00:51:19
Speaker
There currently is an ongoing clinical trial that is actually looking at this specific question, catheter-directed lysis versus anticoagulation, in intermediate high-risk PE patients.
00:51:33
Speaker
And so hopefully we'll have the answer to this question, but we don't in a prospective trial yet.
00:51:38
Speaker
Okay.
00:51:39
Speaker
And amongst the different catheter-directed interventions that you mentioned, so we can give lysis, lysis plus ultrasound, right, the ticos, or embolectomy.
00:51:55
Speaker
There's also no head-to-head comparisons that are available right now, right?
00:52:00
Speaker
No, not available.
00:52:03
Speaker
We've looked at it retrospectively, and outcomes have been similar, meaning that there's equally effective in reducing that RV to LV ratio.
00:52:17
Speaker
And outcomes in terms of, say, in hospital mortality, we have a similar effect for both of them.
00:52:25
Speaker
The risk of bleeding is sort of like a trend towards using the catheter-directed TPA being higher, but it's not significant either.
00:52:34
Speaker
And there's another randomized clinical trial that is on the works as well that is going to be comparing patients
00:52:44
Speaker
catheter-directed TPA or catheter-directed lysis risk with catheter thrombectomy.
00:52:50
Speaker
So we're going to be rapidly evolving.
00:52:53
Speaker
Hopefully in the next five years we'll have answers to all of these questions that are very valid questions, and those are exactly where the
00:53:02
Speaker
where the you know PERTs come into play because there is not necessarily one way of doing things and the guidelines may be a little bit ambiguous.
00:53:14
Speaker
Excellent.
00:53:15
Speaker
So the last question I have regarding the catheter directed therapies is what happens with the anticoagulation once they once they go to the cath lab or the IR suite and come back?
00:53:27
Speaker
So they usually, for the catheter-directed lysis, the anticoagulation is held.
00:53:34
Speaker
If they had low molecular weight heparin, you don't have to hold anything.
00:53:38
Speaker
They already got it, and they're just, you know, then you just don't read those in until...
00:53:42
Speaker
they come back, but they, if you have them on unfractured and heparin, then that heparin is held at a therapeutic level and it's to run through the sheath at a fixed rate.
00:53:55
Speaker
So maybe 500 units, depending on sort of the cath lab or the OR, they have their protocol, but it's sort of like a rate in which you just keep the sheath open so that it doesn't clot, but it's not at a therapeutic range.
00:54:11
Speaker
then the TPA is run depending on the protocol that each institution may have different ones, but they could run from four hours, six hours, eight hours.
00:54:25
Speaker
The ultimate trial was 12 hours, so it really depends on what protocol you use.
00:54:30
Speaker
And all of these strategies of
00:54:32
Speaker
different TPA dosing and durations have been equally effective in reducing the RV to LV ratio.
00:54:38
Speaker
So, you know, the less the better.
00:54:40
Speaker
I think that that's kind of like the short answer.
00:54:43
Speaker
But it's held for that duration in which TPA has been run.
00:54:48
Speaker
Usually people follow fibrinogen levels during that time in case it, you know, overshoots and you need to stop the TPA for the most part.
00:54:57
Speaker
It does not.
00:55:00
Speaker
And then once the catheter is removed with the TPA, then either full-dose heparin or another dose of the low molecular weight heparin is given for the patient.
00:55:14
Speaker
And the patients do really quite well.
00:55:16
Speaker
I think within probably the next 24 hours, they get transitioned to a DOAC, and then they can be moved out of the ICU.
00:55:24
Speaker
So...
00:55:25
Speaker
Even though the procedure itself is probably more costly, if you compare to an ecoagulation alone, obviously, may not be as, maybe similar or same range as TPA.
00:55:38
Speaker
But the fact that they get moved out sooner out of the intensive care unit, it might offset some of the cost and they get discharged sooner home.
00:55:48
Speaker
Excellent.
00:55:49
Speaker
And in terms of escalating therapies, what's the role of surgical embolectomy in these patients?
00:55:57
Speaker
A lot.
00:55:58
Speaker
Super important field.
00:56:00
Speaker
In our institution, for every high-risk PE, we have our surgeon involved for any of these conversations because we want them involved up front.
00:56:12
Speaker
And we want them to know that this patient is here and is sick so that it's on their radar.
00:56:19
Speaker
And it's used for patients who have either failed systemic, failed catheter-directed.
00:56:25
Speaker
And nowadays, in another scenario in which is used, probably the most common scenario for us is clot and transit, which we haven't talked about.
00:56:35
Speaker
Yeah, so clot in the RA and RV, and if they have a PFO especially.
00:56:42
Speaker
So we prefer a surgical approach if catheter cannot be used, depending on the size of the clot.
00:56:53
Speaker
You know, the clot may not fit into the catheter.
00:56:57
Speaker
So that's when the surgical thrombectomy is really important.
00:57:00
Speaker
And we want them involved earlier and sooner rather than later and when they're, you know, decompensating and potentially in cardiac arrest.
00:57:12
Speaker
So any additional comments in terms of the clot in transit?
00:57:17
Speaker
It increases your mortality for sure.
00:57:20
Speaker
And when we see a clot in transit, we kind of like stop breathing for a second.
00:57:28
Speaker
And then that's when we definitely want to move quickly because we know that this could be a very high risk of decompensating and that clot in transit could turn into a cardiac arrest.
00:57:40
Speaker
Excellent.
00:57:41
Speaker
Any comments on mechanical hemodynamic support?
00:57:44
Speaker
So we talked about the high-risk patients, those that would obviously have cardiac arrest or are in shock.
00:57:50
Speaker
There's been a growing interest in...
00:57:53
Speaker
mechanical support throughout different pathologies, but also in PE.
00:57:58
Speaker
And I just wanted to hear a little bit of what your thoughts are and what the guidelines state as of now.
00:58:04
Speaker
Yeah.
00:58:05
Speaker
So, you know, it used to be that you reserve ECMO for later, right?
00:58:09
Speaker
So whenever everything else fails, okay, let's go to ECMO.
00:58:13
Speaker
And the
00:58:16
Speaker
There's actually a recent American Heart Association guidelines that just came out, I think last month.
00:58:23
Speaker
I was part of the group that published this.
00:58:29
Speaker
We need to use ECMO earlier.
00:58:31
Speaker
um because ECMO is it can slow time and PE is a reversible disease so so it's not like you know end-stage heart failure in which you you know put them on ECMO and then you have to move to transplant or you know there's really nothing else that you can do about them but uh for for PEs uh you know um
00:58:53
Speaker
If you treat them with ECMO and you select the patient correctly, they may not even need any of the advanced therapies because the ECMO sort of freezes time and will just allow the RV to, with anticoagulation alone, sort of be able to recover quickly.
00:59:09
Speaker
And it couldn't just be 24, 48, 72 hours.
00:59:15
Speaker
But there is a trend now that we want to get the ECMO team involved earlier, especially those patients that are going to have any of these advanced procedures, because it could turn from a
00:59:30
Speaker
stable patient to an unstable patient, it could just be a matter of a turn or moving from the patient from the stretcher to the calf lap table.
00:59:41
Speaker
They could just arrest.
00:59:43
Speaker
So if you are ready, you may be able to salvage that patient by putting them on ECMO.
00:59:49
Speaker
And then you continue with the procedure as opposed to, you know, wait until the patient's like 20 minutes into the code and then there's, you don't know where that patient will go.
01:00:01
Speaker
Perfect.
01:00:02
Speaker
And I think that there's some case reports of using other mechanical support devices like Impella and Tandem Hearts, but really as of now, the focus of guidelines and what really there's more experience with is with VA ECMO because you need to control both the hemodynamics and the oxygenation in these high-risk patients, correct?
01:00:22
Speaker
Correct.
01:00:23
Speaker
Yeah, most of the experience with mechanical circulatory support is with ECMO.
01:00:29
Speaker
And as we close the discussion on treatment and as we're getting to the end, I do think it's important just if you could share with us some thoughts on IVC filters.
IVC Filters: Use and Risks
01:00:39
Speaker
You did talk about them earlier, but what is the role in PE patients and also how you think about IVC filters today?
01:00:49
Speaker
Avoid at all costs.
01:00:51
Speaker
I think filters, unless you have a patient that has a DVT that is actively bleeding and there's a really strong reason why you cannot anticoagulate, then you should not put them in because it doesn't necessarily change...
01:01:12
Speaker
uh having recurrent clot uh and and most importantly is that people forget to take them out and then they just sort of become embedded and they could just also clot itself and then later on the future cause complications so um i think the the the indication again would be active bleeding and um and lower extremity
01:01:37
Speaker
DVT present, I think that that would be the only scenario in which I would think about in the acute setting.
01:01:45
Speaker
There are some retrieval IVC filters out there on the market that I personally don't have a lot of experience with, but they can just be put on for, say, if the patient needs to have a procedure.
01:01:58
Speaker
Let's just say, I don't know, a neurosurgical patient that needs to have
01:02:02
Speaker
surgery because they have cord compression or something very specific and then they have a DVT and they can put these filters on and then be removed once the anticoagulation can be restarted.
01:02:14
Speaker
So if you can use those, I guess that would be better.
01:02:17
Speaker
But if you end up putting them, then the sooner that you can get them out, the better the outcomes in the long term.
01:02:26
Speaker
Perfect.
01:02:26
Speaker
And I think it's a good segue to finalize our conversation with follow-up.
01:02:32
Speaker
And I know that is something that you're very passionate about with your pulmonary hypertension practice and the type of patients you see outside of the ICU.
01:02:40
Speaker
But a lot of our listeners, like myself, are intensivists, and we kind of think that, okay, the patients transferred out of the ICU, and
01:02:46
Speaker
done, right?
01:02:47
Speaker
But we need to set these patients up for success.
01:02:49
Speaker
Could you share with us some considerations in terms of follow-up and as patients leave the ICU, things that we should be thinking of?
01:02:57
Speaker
Yeah.
01:02:59
Speaker
You know, the important thing about follow-up is that we haven't been doing a really good job in the past about following up these patients.
01:03:07
Speaker
And because of the disease, the nature of this disease is like multidisciplinary, you know, like I think that critical care thought pulmonary was following pulmonary.
01:03:16
Speaker
Pulmonary thought it was hemonc.
01:03:17
Speaker
Hemonc thought it was a primary care.
01:03:18
Speaker
Primary care thought it was pulmonary.
01:03:21
Speaker
And then probably no one really followed up the patient.
01:03:24
Speaker
So I think it's important to recognize that there is sort of under-diagnosis and the follow-up.
01:03:33
Speaker
There's not enough following up of these patients.
01:03:36
Speaker
The most important thing is making sure that they leave the hospital with anticoagulation.
01:03:42
Speaker
DOACs are now, as you know, recommended for most patients as a long-term anticoagulation.
01:03:49
Speaker
And identifying the risk of reclotting is very important because that's going to dictate how long they're going to need to stay on their anticoagulation for.
01:03:58
Speaker
And then following up the patients, we'd like to follow up patients that have intermediate or high-risk PEs because we want to know if they're already recovered.
01:04:07
Speaker
As I mentioned before, we want to get that echocardiogram to make sure that it normalized.
01:04:14
Speaker
And if not, then do we have to screen them for chronic complications such as CTEF?
01:04:20
Speaker
But...
01:04:22
Speaker
Usually, it can be done in a post-BE clinic, it can be done by primary care, it can be done by pulmonary, it can be done by hemonc, it can be done by multiple specialties, but it has to be sort of delineated, and each institution has to be responsible of setting standards of who's going to be responsible, ultimately, in repeating some of these tests.
01:04:45
Speaker
and reassessing anticoagulation and other things like I mentioned, IVC filter retrieval.
01:04:52
Speaker
Is that patient up-to-date in their age-appropriate cancer screening?
01:04:57
Speaker
Do they need any thromophilia workup?
01:05:01
Speaker
Do they have any recurrent disease and could they have antiphospholipid syndrome?
01:05:05
Speaker
And maybe DOAC is not the right anticoagulation.
01:05:09
Speaker
So all these questions have to be looked into after the patient leaves the hospital.
01:05:16
Speaker
And we usually start by seeing the patient, you know, anytime, two weeks to three months, I guess, depending on the patient, depending on availability of our clinic and reassessing symptoms.
01:05:30
Speaker
And if they're symptomatic, then we would obtain echocardiograms.
01:05:36
Speaker
Sometimes we rely on VQ scans and six-minute walk tests as well.
01:05:41
Speaker
But if they're even asymptomatic and their RV was abnormal when they got diagnosed in the acute setting, we will be repeating an echocardiogram at the very least to know that it normalized.
01:05:54
Speaker
Perfect.
01:05:55
Speaker
And I think it's important just to remind our listeners that we want to set up these patients for success, right?
01:06:01
Speaker
And a lot of times data has shown that with poor follow-up, symptoms are unaddressed or there's failures of therapy that are not recognized.
01:06:11
Speaker
And these patients will come back to us and with a higher morbidity and mortality.
01:06:15
Speaker
So thanks for those comments on the follow-up.
01:06:23
Speaker
I want to finish the podcast, Belinda, with some questions that are unrelated to PE, if that's okay.
01:06:31
Speaker
Sure.
01:06:32
Speaker
Excellent.
01:06:33
Speaker
So the first question relates to books.
01:06:35
Speaker
Is there a book or books that have influenced you or that you have gifted often to others?
01:06:42
Speaker
So the most recent book that I read, it's called The Trusted Advisor.
01:06:46
Speaker
It's not related to medicine.
01:06:49
Speaker
And I used it because it has helped in, you know, my career and how to be assertive as an academic medicine physician and has given me leadership skills within my field.
01:07:06
Speaker
But it also has provided me with tools on how to better build that relationship with patients because it gives tips on earning trust and allowing you to become an effective sort of life advisor.
01:07:25
Speaker
So going beyond that sort of doctor-patient relationship into a more personal level.
01:07:33
Speaker
And I really enjoy reading things that are sometimes non-medical to be able to balance out life.
01:07:42
Speaker
For sure.
01:07:43
Speaker
We're all about reading things that are non-medical.
01:07:45
Speaker
I think that ultimately it enriches your medical practice, not only your view of the world.
01:07:51
Speaker
So definitely, I will look into this.
01:07:53
Speaker
I have not read this book, but we'll definitely link it in the show notes.
01:07:56
Speaker
And I'm interested to see what they have to say.
01:07:59
Speaker
The second question, Belinda, relates to beliefs.
01:08:03
Speaker
What do you believe to be true in medicine or in life that most other people don't believe or at least don't act as they believe?
01:08:11
Speaker
I think that one important lesson is that we learn every day.
01:08:19
Speaker
And I think we have to be humble about learning.
01:08:22
Speaker
And there's learning in everything and everywhere.
01:08:25
Speaker
And I think you need to be an active learner and pay a lot of importance in learning.
01:08:34
Speaker
keeping yourself abroad.
01:08:36
Speaker
And this is, you learn in medicine from, you know, medical student to residents to fellows to colleagues, right?
01:08:46
Speaker
But also you learn from patients so much.
01:08:52
Speaker
And that's, it's so important to, just because the patient does not fit that textbook characteristic,
01:09:00
Speaker
but they're still saying they feel those symptoms.
01:09:03
Speaker
I learned from that.
01:09:04
Speaker
And I believe that.
01:09:06
Speaker
I think that's a great, a great point in terms of the really the, the journey to be a lifelong learner and to always have that beginner's attitude, right?
01:09:14
Speaker
That humility to realize that no matter how much we think we know, there's still a lot more for us to learn about any given topic.
01:09:21
Speaker
So I love that.
01:09:23
Speaker
The last question would be like the closing question would be, what would you want every intensivist that's listening to us to know?
01:09:31
Speaker
Could be a quote, a fact, or just a thought.
01:09:34
Speaker
A quote I love that a colleague told me once was, wake up with determination and go to bed with satisfaction.
01:09:45
Speaker
And I
01:09:46
Speaker
It was so eye-opening to me when I heard this, especially obviously in times of COVID and where we are so exhausted and more and more is required from us every day, that it just gives you hope and gives you meaning in what we do day to day.
01:10:08
Speaker
Because sometimes we can get caught up in...
01:10:12
Speaker
the little things making you tired that you forget about the wins.
01:10:18
Speaker
I love it.
01:10:19
Speaker
And I think that is a perfect place to stop.
01:10:23
Speaker
Belinda, thank you so much for all your work on pulmonary embolism and PERT teams.
01:10:27
Speaker
Thank you for sharing your expertise with us today and for your time.
01:10:32
Speaker
Hope to have you back on the podcast to discuss other topics.
01:10:35
Speaker
Thank you very much.
01:10:37
Speaker
You are so welcome.
01:10:38
Speaker
I really had a nice time.
01:10:39
Speaker
Thank you.
01:10:43
Speaker
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01:10:47
Speaker
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01:10:53
Speaker
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01:10:57
Speaker
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