Management of massive and nonmassive pulmonary embolism

Abstract

Massive pulmonary embolism (PE) is characterized by systemic hypotension (defined as a systolic arterial pressure < 90 mm Hg or a drop in systolic arterial pressure of at least 40 mm Hg for at least 15 min which is not caused by new onset arrhythmias) or shock (manifested by evidence of tissue hypoperfusion and hypoxia, including an altered level of consciousness, oliguria, or cool, clammy extremities). Massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. A subgroup of patients with nonmassive PE who are hemodynamically stable but with right ventricular (RV) dysfunction or hypokinesis confirmed by echocardiography is classified as submassive PE. Their prognosis is different from that of others with non-massive PE and normal RV function. This article attempts to review the evidence-based risk stratification, diagnosis, initial stabilization, and management of massive and nonmassive pulmonary embolism.

Keywords: anticoagulation; embolectomy; pulmonary embolism; thrombolysis.

Figure 1

Pathophysiology of cardiovascular collapse following massive pulmonary embolism RV – right ventricle, LV – left ventricle, RVEDP – right ventricular end-diastolic pressure, MAP – mean arterial pressure, RV CPP – right ventricular coronary perfusion pressure

Figure 2

Current established regimen for management of pulmonary embolism