J Thromb Haemost. 2023 May 13:S1538-7836(23)00409-9. doi: 10.1016/j.jtha.2023.05.003. Online ahead of print.
Around 5% of pulmonary embolism (PE) cases present with persistent hypotension, obstructive shock or cardiac arrest. Given the high short-term mortality, management of high-risk PE cases focuses on immediate reperfusion therapies. Risk stratification of normotensive PE is important to identify patients with an elevated risk of hemodynamic collapse or an elevated risk of major bleeding. Risk stratification for short-term hemodynamic collapse includes assessment of physiological parameters, right heart dysfunction and identification of comorbidities. Validated tools such as the ESC guidelines and Bova score can identify normotensive PE patients with an elevated risk of subsequent hemodynamic collapse. At present, we lack high-quality evidence to recommend one treatment over another (systemic thrombolysis, catheter-directed therapy or anticoagulation with close monitoring) for patients at elevated risk of hemodynamic collapse. Newer, less well validated scores BACS and PE-CH may help identify patients with a high risk of major bleeding following systemic thrombolysis. The PE-SARD score may identify those at risk of major anticoagulant-associated bleeding. Patients at low risk of short-term adverse outcomes can be considered for outpatient management. The sPESI score or Hestia criteria are safe decision aids when combined with physician global assessment of the need for hospitalization following the diagnosis of PE.
PMID:37187357 | DOI:10.1016/j.jtha.2023.05.003