Dec 17, 2019
Welcome to the first episode of
PERTCast, the official podcast of the PERT Consortium!
Episode 1: Oren Friedman
interviews Vic Tapson about risk stratification of the pulmonary
Oren Friedman MD
Associate Director, Cardiac Surgery ICU
Pulmonary Critical Care
Cedars-Sinai Medical Center
Professor of Medicine
Director, Venous Thromboembolism and Pulmonary
Vascular Disease Research Program
Associate Director, Pulmonary and Critical Care
Cedars-Sinai Medical Center
PE risk stratification Pearls: history and
- Patient’s appearance and vitals (initial and
trend) are most important parts of risk stratification
- Syncope can have a wide differential. Syncope
in setting of PE can have significant consequences.
- Patient resting comfortably can be reassuring,
but at the same time ask- what happens on exertion, to gauge the
severity of symptoms (i.e. dizziness, near syncope
- Profound hypoxemia is under recognized in PE
- European Society of Cardiology (ESC) integrates
PESI, and sPESI score that is much more practical way of PE
classification divide PE into Intermediate PE (Submassive PE) in to
two categories- Intermediate high risk (positive sPESI score, RV
dysfunction and biomarker positivity) or Intermediate low risk
(Positive sPESI score, and RV dysfunction or biomarker
classification is heterogeneous, patient’s hemodynamics can evolve,
so will be their risk stratification score.
Biomarkers in PE risk stratification:
- Troponin more sensitive than BNP. Be careful
for false positives (elevated BNP in chronic heart
- Lactic acid can provide prognostic information
in setting of PE.
CTA based risk stratification:
- Contrast reflux into IVC/Liver
burden, 40% occlusion of pulmonary circulation can be associated
with high PE related mortality.
- Normal RV can’t generate systolic pressure in
the excess of 50-60 mm Hg.
- Elevated PA systolic pressure >70-80 mm HG
suggest chronic component of RV failure
need to have good systolic function to generate high PA
is not the holy grail of RV dysfunction, interpret with
- Extensive DVT (above knee) with higher risk PE
have worse outcomes.
- Patient activity (few days to weeks) should be
filter should not be considered in every case of PE with
patient with acute PE should be promptly
- Change in vital trends or persistently abnormal
vital signs may help in consideration of advance reperfusion
strategies in same PE category.
Take home message:
at patient’s appearance + Vitals (HR, RR) and add other objective
measures (sPESI, Biomarkers, imaging) + Residual clot burden in
- Activate the multidisciplinary PERT to leverage
input from local experts.
- Konstantinides SV, Torbicki A, Agnelli G, et
al. 2014 ESC guidelines on the diagnosis and management of acute
pulmonary embolism. Eur Heart J. 2014;35(43):3033-69,
- Jiménez D, Aujesky D, Moores L, et al.
Simplification of the pulmonary embolism severity index for
prognostication in patients with acute symptomatic pulmonary
embolism. Arch Intern Med. 2010;170(15):1383-9.
der meer RW, Pattynama PM, Van strijen MJ, et al. Right ventricular
dysfunction and pulmonary obstruction index at helical CT:
prediction of clinical outcome during 3-month follow-up in patients
with acute pulmonary embolism. Radiology.
- Prandoni P, Lensing AW, Prins MH, et al.
Prevalence of Pulmonary Embolism among Patients Hospitalized for
Syncope. N Engl J Med. 2016;375(16):1524-1531.
- Becattini C, Cohen AT, Agnelli G, et al. Risk
Stratification of Patients With Acute Symptomatic Pulmonary
Embolism Based on Presence or Absence of Lower Extremity DVT:
Systematic Review and Meta-analysis. Chest.
E, Tenías JM, Soto MJ, et al. D-dimer levels correlate with
mortality in patients with acute pulmonary embolism: Findings from
the RIETE registry. Crit Care Med. 2007;35(8):1937-41.