Pulmonary embolism treatments continue to evolve
Pulmonary embolism (PE), a potentially fatal cardiovascular condition, remains a clinical challenge due to the lack of standardized treatment protocols.
Cardiovascular Business asked Sahil Parikh, MD, director of endovascular services at New York-Presbyterian Columbia University Irving Medical Center and associate professor of medicine at Columbia University, what his thoughts are on the current PE standard of care. He said there is a lot of uncertainty in the evolving landscape, but emphasized the importance of PE management as a major cardiovascular diagnosis. He also urged his peers to become more engaged in its management, especially as interest increases for catheter-based therapies.
"PE is one of the top three cardiovascular killers and often underdiagnosed," Parikh explained. "Providing invasive therapies that can reduce morbidity and mortality and expedite recovery is incredibly gratifying and crucial for addressing this unmet clinical need."
Traditionally, systemic thrombolysis has been used to dissolve the clots, similar to how myocardial infarction (MI) patients were treated decades ago before catheter based treatments. Parikh said modern practices have shifted significantly over the past decade to catheter-based technologies due to lytics being associated with higher risks of hemorrhage and the scant clinical data.
"For PE, particularly in patients at the highest risk – those with massive PE and cardiogenic shock – the mortality rates are alarming, hovering between 40 and 50%," Parikh explained. "Despite these figures, the primary intervention, thrombolysis, is seldom used due to the high risk of hemorrhage and the limited data from small-scale studies."
He said there is clearly a need for more comprehensive research. In fact, the key trial pointed to for the safety and efficacy of thrombolysis consisted of just eight patients. In the absence of robust clinical guidelines, clinicians are often required to make judgment calls based on individual patient presentations, he said.
New treatments for PE
Emerging treatments for massive PE cases now include mechanical circulatory support such as ECMO (extracorporeal membrane oxygenation) and acute embolectomy, either surgically or via catheter-directed techniques. These catheter-based therapies include mechanical thrombectomy and ultrasound-assisted catheter-directed thrombolysis (USCDT). However, these methods are yet to be validated by large-scale randomized controlled trials (RCTs) and are not universally endorsed as a standard care.
For the majority of PE patients, particularly those at low risk without hemodynamic compromise or right ventricular dysfunction, he said the treatment is more straightforward. These patients are typically managed with oral anticoagulants and often discharged quickly, sometimes directly from the emergency department.
The greatest focus, however, is on the intermediate-risk group, especially those with high intermediate risk, where in-hospital mortality can reach 25% despite anticoagulant therapy.
"These patients represent a particularly high-risk population, potentially more so than those with ST-elevation myocardial infarction (STEMI)," Parikh said. "Risk stratification algorithms, although imperfect, help identify patients who might benefit from more aggressive treatments."
The approach to intermediate-risk patients often involves a detailed assessment of right ventricular function, cardiac biomarkers, and hemodynamic stability. Patients showing signs of cardiogenic shock, despite normal blood pressure, are considered for advanced therapies.
At institutions like New York-Presbyterian, the pulmonary embolism response team (PERT) model plays a crucial role in managing PE cases. This team-based approach ensures a consensus-driven diagnostic and therapeutic strategy, which has streamlined patient care and improved outcomes. Cardiology has become increasingly involved in PERT teams at many hospitals.
Interventional cardiology is increasingly involved in PE treatment, particularly for patients with right ventricular dysfunction. Parikh said this involvement is part of a broader trend of interventional cardiologists expanding their roles to address complex cardiovascular conditions beyond traditional heart attacks and strokes.
As the field awaits more definitive data from ongoing RCTs, the treatment of PE will continue to evolve, driven by a combination of emerging therapies and clinician expertise.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com