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New ESC PE guidelines – still muddled in the middle?

RV overload The new European PE guidelines from the ESC appear to start applying some of the evidence regarding patients without shock but with RV strain and elevated troponin/BNP.

Remember the sPESI – 1 point for: cancer, COPD, chronic heart failure, age >80, sats<90%. Any of these put the patient into the intermediate (30 day mortality) risk group at least. This group is divided into intermediate-high and intermediate-low using the presence of RV dysfunction (or dilatation) and elevated troponin/BNP. However no clear therapeutic reason for the division is given.

PE algorithmIdeally CT angiogram, but echo is emphasised as the imaging of choice where time or facilities are lacking.

500 ml fluid bolus is considered enough. Brief discussion of inotropes and pressors: noradrenaline (an RV inotrope) if hypotensive with adequate cardiac output, maybe dobutamine if more cardiac output required, adrenaline for a ‘balanced’ approach.

Ventilation should be expected to worsen venous return and RV function, so avoid or approach very cautiously and limit pressures accordingly.

Thrombolysis:

  • Thrombolyse high risk and accept the 1-2% haemorrhage risk.
  • Don’t thrombolyse anyone else routinely.
  • Watch the intermediate-high risk group closely to pick up transition into shock/high-risk.
  • Catheter-directed thrombolysis requires experts but is well-regarded if light on evidence.

If high risk and thrombolysis is contraindicated:

  • Rheolytic/suction/rotational thrombectomy or catheter fragmentation by an expert.
  • Surgical embolectomy should be done where there is good experience.

Anticoagulation remains the mainstay with the novel oral anticoagulants now beginning to look superior in terms of safety ‘v’ vitamin K antagonism.

IVC filters are short on evidence. Little choice if anticoagulation is contraindicated but surgery not warranted. May reduce recurrence of PE but increase DVT.

So despite these comprehensive guidelines delineating the intermediate-high risk group there is no firm belief that thrombolysis is the right thing. Fancy a half-dose?

 

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