Emergent pulmonary embolism management in hospital practice : from hyperacute to follow up care

Pulmonary embolism (PE) has experienced a rapid expansion in available treatments, from hyperacute emergency care to the detailed investigation of persistent breathlessness despite anticoagulation during follow up. Whilst recent clinical practice guidelines provide a robust evidence base for more routine aspects of pulmonary embolism management, clinicians frequently face patient-specific challenges where the evidence for how to proceed with patient management may be less secure. Derived from the personal experience of expert clinicians who are engaged in all aspects of PE care, this book provides a practical update on contemporary management aspects from life-threatening presentation of pulmonary embolism with failed thrombolysis to the patient presenting with complex comorbidity or during pregnancy. General physicians and clinical specialists interested in contemporary diagnosis and management of acute pulmonary embolism will benefit from this book. Readership: Hospital clinicians, undergraduate and postgraduate trainees, acute internal medicine specialists, cardiologists, pulmonologists, haematologists, specialist nurses (anticoagulation), medical students. Contents Preface About the Editors List of Contributors Part 1 Acute Care Chapter 1 Getting the Diagnosis of Acute Pulmonary Embolism Right — Which Diagnostic Strategy? Introduction Diagnostic Strategies Step 1: Assessment of Clinical Pre-Test Probability Step 2: D-Dimer Testing Imaging Tests Computed tomographic pulmonary angiography Ventilation–perfusion lung scan Single-photon emission computed tomography Challenges in Specific Patient Populations Elderly patients Patients with cancer Pregnant patients Patients with COVID-19 Conclusion Bibliography Chapter 2 Correct Risk Stratification at Diagnosis — Why It Matters? Clinical Case Clinical Clues Risk Scores Electrocardiography Laboratory Studies Cardiac biomarkers Imaging Studies Chest computed tomography Echocardiography An Integrated Approach to Risk Stratification Multidisciplinary PE Response Team Role in Risk Stratification The Impact of Risk Stratification on Decision-Making Clinical Case Conclusion Bibliography Chapter 3 Outpatient Management of Pulmonary Embolism: Who Can I Send Home? Introduction: Defining Outpatient Why Manage Patients with PE as an Outpatient? Risk Stratification Clinical presentation Risk scores Pulmonary Embolism Severity Index (PESI) and simplified PESI (sPESI) Geneva score Hestia criteria Other scores Raised cardiac biomarkers Right ventricular dilatation Clinical Application of PE Guidelines Pulmonary Infarcts and Early Discharge Approach to the Use of Cardiac Biomarkers and Measures of Right Ventricular Dilatation Clot Burden and Distribution and Early Discharge Outpatient Management of PE in Pregnancy Clinical Cases Case 1 Case 2 Summary Bibliography Part 2 Emergencies Chapter 4 Navigating the Acute Treatment Landscape: An Overview Introduction Initial Risk Stratification The PE Response Team Haemodynamically Unstable Pulmonary Emboli Initial resuscitation, anticoagulation, and diagnosis Definitive Reperfusion Therapy Systemic thrombolysis Surgical pulmonary embolectomy Catheter-directed therapies Post-reperfusion anticoagulation Haemodynamically Stable PE Completion of risk stratification Treatment of Haemodynamically Stable PE Systemic thrombolysis Catheter-directed therapies Anticoagulation Changes in Clinical Status Conclusion Bibliography Chapter 5 Systemic Thrombolysis in Acute Pulmonary Embolism: Dose Considerations in Administration of Thrombolytics Introduction Pharmacology of Thrombolytics Indications Risk Stratification and Use of Thrombolysis High risk Intermediate risk Low risk Right heart thrombi Logistics of Administration Preparation After thrombolysis In the event of major bleed Risks and Contraindications Full versus Reduced Dosing Clinical Considerations Cardiac arrest Neurologic population Conclusion Bibliography Chapter 6 Catheter-Directed Thrombolysis versus Mechanical Thrombolysis: Who to Consider and What to Expect Background Indications for Interventional Reperfusion Therapy Interventional Reperfusion Techniques Catheter-directed thrombolysis Mechanical thromboaspiration Pre- and Peri-Procedural Considerations Cardiopulmonary resuscitation Anticoagulation Procedural technique Post-procedural considerations Considerations in the Patient on ECMO Outcomes Complications Summary Bibliography Chapter 7 ECMO Referral and Right Ventricular MCS: When Should These Be Considered? Background Brief History and Background to ECMO Pathophysiology of RV Failure in Massive PE Intensive Care Management of Massive PE ECMO for Massive PE Suitability and timing Referral, retrieval, and cannulation Ongoing Management of ECMO Support in Patients with Massive PE Anticoagulation and thrombolysis Embolectomy, clot disruption, and aspiration Ongoing monitoring Weaning from ECMO in Massive PE Outcomes of Patients with PE Supported with ECMO Conclusion Bibliography Part 3 Special Situations Chapter 8 Acute Pulmonary Embolism with Comorbidities — How Should I Change My Approach? Introduction Malignancy Anticoagulation in malignancy-associated PE Asymptomatic incidental PEs in patients with malignancy Treatment of PE in patients with primary or metastatic brain tumours Anticoagulation beyond 6 months Obesity Choice of anticoagulant for PE in obese patients Initial anticoagulation Long-term therapy Dose adjustment of anticoagulants in obese patients Long-term anticoagulation therapy for obesity-associated PE Treatment of PE following bariatric surgery Chronic Kidney Disease Anticoagulation in CKD Parenteral anticoagulation Oral anticoagulation Haematological Conditions Anticoagulation in thrombocytopenia Bibliography Chapter 9 Acute Pulmonary Embolism with Right Heart Thrombus — Does a Patent Foramen Ovale Matter? Acute Pulmonary Embolism with Right Heart Thrombus Epidemiology and pathophysiology Diagnosis Implications for management Prognostic significance Acute PE with Patent Foramen Ovale Epidemiology, pathophysiology, and diagnosis Paradoxical embolism: Definition, mechanisms, and implications for management Acute PE and PFO as a Cause of Severe Hypoxaemia Acute PE and PFO: Implications for Management Prognostic Implications of PFO in PE Bibliography Chapter 10 Acute Pulmonary Embolism in Pregnancy Case Epidemiology Diagnosis Symptoms, ECG, and laboratory testing Imaging Risk stratification Treatment Rescue therapy Outcomes and Case Follow-Up Summary Bibliography Chapter 11 Recurrent PE on Anticoagulation — What Should I Do Differently? Introduction Investigations Diagnosis of Acute (Recurrent) PE Use of Clinical Pre-Test Probability Assessment Tools Use of Biomarkers Imaging in Acute (Recurrent) PE Why was There a Recurrence? Non-compliance Screening for thrombophilia Screening for cancer Management of the Acute (Recurrent) PE How is Anticoagulation Managed in Patients with Recurrent PE in the Acute Setting? Follow-Up and Long-Term Management Risk of recurrence Post-anticoagulation imaging Which long-term anticoagulation? Conclusion Bibliography Chapter 12 Pulmonary Embolism with Contraindications to Anticoagulation — How to Proceed Introduction What is a Contraindication? Assessment of Bleeding Risk Management of VTE in the Neurologic or Neurosurgical Setting Management of VTE in Pregnancy Management of PE in the Setting of Cancer Conclusion Bibliography Part 4 Follow-Up Chapter 13 Anticoagulation: Which Agent and for How Long? Introduction Outpatient Anticoagulant Medication Classes Vitamin K antagonists What to consider when using VKAs? Direct oral anticoagulants Indirect thrombin inhibitors Indirect factor Xa inhibitors Selecting the Most Appropriate Anticoagulant for Your Patient Anticoagulant preference in specific patient populations Important Counselling Points For How Long? Conclusion Bibliography Chapter 14 Follow-Up Assessment — Who to Follow and How to Investigate? Introduction Why Follow-Up Patients with Acute PE? Screening for malignancy and thrombophilia What to Assess at a Follow-Up Visit 3–6 Months after PE What Alternative Diagnoses Should I Consider in Post-PE Breathlessness? Deconditioning Dysfunctional breathing Autonomic dysfunction Points of Contention Summary Bibliography Chapter 15 Long-Term Breathlessness Despite Anticoagulation — What are the Treatment Options? Introduction Post-PE Syndrome Physiological Mechanisms Ventilation–perfusion (V/Q) mismatch RV dysfunction and uncoupling Chronotropic incompetence and impaired peripheral extraction Management Pulmonary endarterectomy Balloon pulmonary angioplasty Medical therapy Conclusion Bibliography Chapter 16 COVID-19-Associated Thrombosis Introduction Pathogenesis Vascular endothelial injury Immunothrombosis Fibrin deposition and fibrinolysis Platelets Complement Autoantibodies including antiphospholipid antibodies COVID-19: Thrombotic and thromboembolic clinical manifestations VTE: Screening and Diagnosis Imaging Blood parameters FBC including platelet count PT/APTT Fibrinogen D-dimer Viscoelastic (VE) assays Management Thromboprophylaxis Antiplatelet Treatment Recommendations Management of Acute Thrombosis Choice of Anticoagulant Monitoring Management of Patients Already on Anticoagulation on Admission Withholding Anticoagulation Thrombolysis: Systemic and Catheter-Directed Additional Respiratory Management Follow-Up: Haematological Management Is there a role for follow-up assessment with D-dimer in patients with COVID-19? Follow-up: Respiratory Conclusion Acknowledgement Bibliography Index "Pulmonary embolism (PE) has experienced a rapid expansion in available treatments, from hyperacute emergency care to the detailed investigation of persistent breathlessness despite anticoagulation during follow up. Whilst recent clinical practice guidelines provide a robust evidence base for more routine aspects of pulmonary embolism management, clinicians frequently face patient-specific challenges where the evidence for patient management may be less secure. Derived from the personal experience of expert clinicians engaged in all aspects of PE care, this book provides a practical update on contemporary management aspects from life-threatening presentation of pulmonary embolism with failed thrombolysis to the patient presenting with complex comorbidity or during pregnancy. General physicians and clinical specialists interested in contemporary diagnosis and management of acute pulmonary embolism will benefit from this book"-- Provided by publisher