Recent advances in the management of pulmonary embolism: focus on the critically ill patients

Abstract

The aim of this narrative review is to summarize for intensivists or any physicians managing "severe" pulmonary embolism (PE) the main recent advances or recommendations in the care of patients including risk stratification, diagnostic algorithm, hemodynamic management in the intensive care unit (ICU), recent data regarding the use of thrombolytic treatment and retrievable vena cava filters and finally results of direct oral anticoagulants. Thanks to the improvements achieved in the risk stratification of patients with PE, a better therapeutic approach is now recommended from diagnosis algorithm and indication to admission in ICU to indication of thrombolysis and general hemodynamic support in patients with shock. Given at current dosage, thrombolytic therapy is associated with a reduction in the combined end-point of mortality and hemodynamic decompensation in patients with intermediate-risk PE, but this is obtained without a decrease in overall mortality and with a significant increase in major extracranial and intracranial bleeding. In patients with high-intermediate-risk PE, thrombolytic therapy should be given in case of hemodynamic worsening. Vena cava filters are of little help when anticoagulant treatment is not contraindicated, even in patients with PE and features of clinical severity. Finally, direct oral anticoagulants have been shown to be as effective as and safer than the combination of low molecular weight heparin and vitamin K antagonist(s) in patients with venous thromboembolism and low- to intermediate-risk PE.

Keywords: Pulmonary embolism; Right ventricle; Risk stratification; Thrombolysis.

Fig. 1

Proposal for hemodynamic management in high-risk PE: *in the absence of contraindication; **may improve the coupling between the right ventricle and the pulmonary circulation by increasing the RV contraction and decreasing the pulmonary vascular resistance. RV right ventricle, LV left ventricle, CTPA computed tomography pulmonary angiography, CO cardiac output, MV mechanical ventilation, NO nitric oxide inhalation, VA ECMO veno-arterial extracorporeal membrane oxygenation