Conservative management in high-risk pulmonary embolism.

Abstract

Introduction: Pulmonary embolism (PE) is the migration of a thrombus from the venous system to the pulmonary vasculature. PE is a significant health problem with high morbidity and mortality. In the US, PE occurs in 302 per 100,000 patients and accounts for over 100,000 deaths annually. Massive PE is associated with signs of hemodynamic instability, while submassive PE is defined by right ventricular dysfunction without hypotension. Therefore, it is of paramount importance to prevent, diagnose, and treat this pathology early. Treatment can be conventional, such as anticoagulation, or invasive, such as thrombectomy and thrombolysis, depending on the clinical presentation and risk factors of each patient. In cases of patients with persistent deep vein thrombosis and a high risk of recurrence, an inferior vena cava (IVC) filter can be placed. IVC filters are mechanical devices designed to prevent emboli from the lower extremities from traveling to the lungs and may therefore provide benefit in high-risk patients. Their use is indicated when anticoagulation is contraindicated or when, despite treatment, there is no improvement, or the patient has extensive proximal deep vein thrombosis or cancer.

Case Report: An 80-year-old patient with a history of hypertension, type 2 diabetes mellitus, Parkinson's disease, and a left hip fracture 6 days prior, who underwent hip replacement surgery 2 days prior, re-presented to the emergency department with sudden onset of dyspnea, chest pain, diaphoresis, tachypnea of 29 breaths/min, tachycardia of 125 bpm, hypotension of 90/60 mmHg, and oxygen saturation of 80%. Based on the clinical presentation and risk factors, pulmonary embolism was suspected with an intermediate-risk Wells score, a high-risk PESI score, and a D-dimer of 2645.85 ng/dL. A chest CT angiography revealed acute and chronic intraluminal thrombi in the right and left pulmonary arteries, confirming the diagnosis. Relevant laboratory findings included troponin I 0.33 ng/mL, troponin T 145 ng/L, NT-proBNP 25188.0 pg/mL, and prolonged prothrombin time (PT) and partial thromboplastin time (PTT).

Conclusion: Pulmonary embolism carries a high risk of mortality, and early and appropriate treatment has been shown to reduce mortality. Conventional treatments with anticoagulation are practical and suitable for high-risk patients who are not candidates for invasive procedures. In patients at high risk of pulmonary embolism, the use of IVC filters has been shown to decrease the recurrence of pulmonary embolism compared to anticoagulation alone but has not been shown to improve long-term survival. Therefore, further studies are needed, as the current use of IVC filters is based more on clinical criteria and medical experience.