Treatment

The options for treatment of PE include anticoagulation, thrombolysis, and (rarely) surgery. With controlled trials ongoing, no clear recommendation yet exists for throm-bolysis in all cases of PE. One trial of alteplase plus heparin showed significantly decreased mortality in patients with submassive PE, compared with patients treated only with heparin (Konstantinides et al., 2002). However, a meta-analysis of all RCTs comparing thrombolytic therapy with heparin in patients with PE showed a survival benefit only in studies that included hemodynamically unstable patients (patients with massive PE). In trials that excluded these patients, there was no benefit found for thrombolysis (mortality slightly worse for thrombolytic therapy) (Wan et al., 2004). Treatment of DVT with thrombolytics has also been studied, and although venous blood flow may be improved and post-DVT syndrome decreased, there is a significant risk of hemorrhagic complications such as stroke.

Table 18-5 Diagnostic Tests to Exclude or Confirm Diagnosis of Pulmonary Embolism (PE)

In massive PE with cardiovascular collapse, thrombolysis is often used, but emergency pulmonary embolectomy is an option in settings where cardiothoracic surgery can be mobilized rapidly. Dauphine and Omari (2005) reported on 11 patients with massive PE treated with emergency embolec-tomy. Of the seven patients who did not have preoperative cardiac arrest, all survived to hospital discharge. One of the four patients who experienced cardiac arrest preoperatively also survived to discharge.

For patients who are hemodynamically stable and have less than massive pulmonary emboli, the initial treatment choice is dose-adjusted, intravenous unfractionated heparin or fixed-dose, subcutaneous low-molecular-weight (LMW) heparin. A meta-analysis comparing these two therapies in venous thromboembolism treatment found odds ratios favoring LMW heparin in both the rate of recurrence and the rate of bleeding complications, but these differences were not statistically significant (Erkens and Prins, 2010). LMW heparin by fixed-dose subcutaneous injection is at least as safe and effective as traditional dose-adjusted, unfraction-ated heparin therapy. Anticoagulation with warfarin is indicated for at least 3 to 6 months after an initial PE episode, and lifetime therapy may be warranted for patients with hypercoagulability or recurrent episodes. Patients with recurrent episodes unresponsive to anticoagulation might benefit from surgical placement of an inferior vena cava filter.

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