Pulmonary Embolism: Scope of the Problem

Transcription

1 Pulmonary Embolism: Scope of the Problem Rachel P. Rosovsky, MD, MPH Director, Thrombosis Research, Hematology, Massachusetts General Hospital Assistant Professor of Medicine, Harvard Medical School Disclosures Rachel P. Rosovsky, MD, MPH Research Support: Janssen, BMS Advisory: Portola Consultant: Bayer 2 Case 1 36 M s/p knee surgery on aspirin presents to OSH after near syncope while sitting on toilet. Dizzy, Dyspneic BP 80/55, HR 110, SaO2 85% RA. Heparin started. Transferred to MGH. Elevated Troponin and BNP. Echo showed RV strain and large volume of thrombus in transit. 3 OSH: outside hospital MGH: Massachusetts General Hospital 1

2 Case 1: Embolus in Transit 4 Case 1 (ARS Question 1) What would you do? A. Continue heparin and observe B. Low molecular heparin and observe C. Systemic thrombolysis with 50 mg or 100 mg tpa D. Surgery E. Catheter directed thrombolysis F. Catheter thrombectomy or PE G. Have no idea 5 Pulmonary Embolism: Scope of the Problem 6 2

3 7 Venous Thromboembolism: The Third Leading Cause of Cardiovascular Death DVT 2 Million Post-thrombotic Syndrome 800,000 PE 5-600,000 Deaths 100,000 Silent PE 1 Million Pulmonary Hypertension 30,000 Estimated Cost of VTE Care $1.5 Billion/year Hirsh J and Hoak J. American Heart Association Heit J et al. Blood. 2005;106: Abstract 910. Anderson FA et al. Am J Hematol. 2007;82: Incidence is increasing 9 Am J Hematol Feb;86(2): Heit, Thromb Hemost,

4 Not Just the United States Konstantinides. JACC Virchow s Triad 2015 VENOUS INJURY Surgery Trauma Prior DVT Burns Fracture STASIS Anesthesia Hospitalization Immobilization CHF/MI CVA Shock Pregnancy Obesity HYPERCOAGULABILITY Inherited Coagulopathy Acquired Coagulopathy Pregnancy/Parturition Hormonal Therapy Malignancy 11 Cleve Clin J Med 1999;66: Heavy D dies suddenly due to pulmonary embolism caused by deep vein thrombosis. No One is Immune Brian Veckers Jimmy Stewart NBC correspondent David Bloom dies of a pulmonary embolism 4

5 Why worry about Pulmonary Embolus? Fatal within 1 h after the onset of symptoms in 10% of cases Untreated PE mortality rate ~30% 13 Pathophysiology of Pulmonary Embolism 14 Abrahams van-doorn P. and Hartmann IJC. Imaging Insights. 2011; 2: Eur Heart J Nov 14;35(43): , 3069a-3069k Pulmonary Embolism Types MASSIVE Shock / Hypotension SUBMASSIVE Normotensive + RV Strain LOW RISK None of the above 15 5

6 Most Patients with PE do Well, but some do not 16 Becattini C, Agnelli G. Thromb Haemost. 2008; 100(5): Abrahams van-doorn P. and Hartmann IJC. Imaging Insights. 2011; 2: Dalen JE. Chest. 2002; 122: PE Mortality (ICOPER) 52.4%* 15% *62.5% from recurrent PE 17 Kucher et al Massive PE Circulation Chronic Thrombotic Pulmonary Hypertension (CTEPH) 6

7 Post-PE Syndrome At one year: 46.5% had exercise limitation; percent predicted V0 2 <80% Kahn. CHEST 2017; 151(5): Pulmonary Embolism: Treatment Options 20 Lots of Options How do you decide? Catheter Directed Thrombolysis Anticoagulation Pulmonary Embolectomy Suction Embolectomy (VORTEX) IVC Filter ECMO: Extracorporeal Support 7

8 Weighing the Risks and Benefits of Intervention Weighing the Risks and Benefits of ICH Intervention Early Mortality VTE Recurrence Functional Limitations Post-thrombotic Syndrome Post-PE Syndrome CTEPH Major Bleeding Clinical Decompensation Case 1: Multi-disciplinary Collaborative Decision-Making 36 M s/p knee surgery who presents near syncope Saddle PE and clot in his RV PERT reviewed options No clear answer as to most optimal, least risky. Vortex would be reasonable approach. BUT Pulmonary Embolism Response Team conference call Right Atrial Embolectomy 24 8

9 Pulmonary Embolectomy 25 Embolic Material Right atrium Left PA Right PA 26 Case 1: Postoperative course Follow Up 9

10 Updates in Pulmonary Embolism: Where are we in 2018? PE is a major cause of morbidity and mortality Numerous treatment options Anticoagulation Advanced Therapies Post PE Complications Cases PERT: novel approach to PE care Thank you rprosovsky@partners.org 10

11 Treatment Options for Acute Pulmonary Embolism: How Do I Choose an Anticoagulant? VuMedi Webinar Series Updates in Pulmonary Embolism: Where Are We In 2018? May 9, 2018 Disclosures No disclosures, financial or otherwise, relevant to this presentation Treatment Phases of VTE (DVT + PE) ± Advanced therapies (e.g. lysis, filter) UFH LMWH Fondaparinux Rivaroxaban Apixaban Acute induction ~ 0 to 7 days Recurrence risk 40% LMWH (cancer) Warfarin Rivaroxaban Apixaban Dabigatran Edoxaban Long-term treatment Up to 3 months Recurrence risk 10% LMWH (cancer) Warfarin Rivaroxaban Apixaban Dabigatran Edoxaban* Extended treatment >3 months to indefinite Recurrence risk varies * Up to 12 months Kearon C, et al. Chest. 2012;141(2)(Suppl):e419s-e494s Kearon C, et al. NEJM 1997; 336:

12 Risk Stratification of PE (massive) (submassive) Primary reperfusion + anticoagulation Anticoagulation ± rescue reperfusion Anticoagulation ± early discharge Initial Anticoagulant Therapy Potential need for advanced therapies (e.g., thrombolysis for massive or submassive PE) Basic tenets of IV UFH for acute PE treatment Once procedures complete, several anticoagulants available for acute phase treatment/induction IV unfractionated heparin (UFH) offers most flexibility (reversible, short t 1/2 ) No role for longer-acting or oral agents in this situation Weight-based dosing with a bolus Adjusted per standardized nomogram Goal: therapeutic levels as quickly as feasible Large RCTs of DOACs vs. warfarin for VTE excluded patients requiring advanced therapies 1-6 Accumulating evidence DOACs may be a reasonable option after catheter-directed thrombolysis (CDT) of PE 1) Schulman S et al. Circ 2014; 129 (7): ) Schulman S, et al. NEJM 2009; 361: ) Agnelli G et al. NEJM 2013; 369: ) Bauersachs R, et al. NEJM 2010; 363: ) Buller HR, et al. NEJM 2012; 366: ) Buller HR, et al. NEJM 2013; 369: How Do I Choose an Anticoagulation Regimen? 2 broad options Conventional approaches (parenteral+/- warfarin) DOACs Choice of approach should based on: Best efficacy and safety profile Patient characteristics Anticoagulant properties Potential barriers to care Cost, coverage, retail availability Patient willingness & ability Transportation, geography Patient preferences 2

13 DOACs: Advantages Improved pharmacokinetic/pharmacodynamic profile Linear kinetics Rapid onset/offset of action Fewer dietary and drug interactions Wide therapeutic window allows fixed dosing No need for routine monitoring Greater convenience and satisfaction Improved safety profile compared to warfarin Potentially more cost-effective for healthcare system overall Chai-Adisaksopha, et al. Blood 2014; 124(15): Bauer KA. ASH Education Book 2013; 1: Ruff CT, et al. Lancet 2013; 383 (9921): Van Der Hulle T, et al. J Thromb Haemost 2014; 12: DOACs vs. LMWH/Warfarin for Acute VTE Efficacy: First recurrent VTE or VTE-related death Safety Meta-analysis; N=27, van Es N et al. Blood. 2014; 124: Updated VTE Guidelines and Guidance ACCP (CHEST) 2016 Guidelines DOACs are preferred over conventional approach with initial parenteral overlapped with warfarin for noncancer associated VTE (Grade 2B) AC Forum VTE guidance compendia (2016) DOACs are suggested as an alternative to conventional therapy for non-cancer VTE treatment in patients who meet appropriate patient selection criteria For all other non-cancer VTE patients, suggest VTE treatment with conventional therapy (warfarin + parenteral) Kearon C, et al. CHEST 2016 doi: /j.chest Burnett AE, et al. J Thromb Thrombolysis (2016) 41:

14 Which VTE patients are good DOAC candidates? All of them until proven otherwise DOAC patient selection criteria No need for advanced or invasive therapies at initial presentation No contraindications (pregnant, breastfeeding, mech. valve, unstudied population/indication, weight < 50 or > 120 kg) Adequate organ function Avoid if CrCl < 30 ml/min by Cockroft-Gault Avoid in moderate to severe hepatic impairment (Child-Pugh B or C) Lack of significant drug interactions Highly likely to adhere to therapy Confirmed ability to obtain DOAC longitudinally Anticoagulation for VTE Conventional VTE treatment Dabigatran Edoxaban Rivaroxaban Apixaban Day 1 Day 1 Day 1 LMWH * Bridging (overlap) LMWH* Switching (no overlap) Day 6-11 Warfarin At least 3 months Dabigatran 150 mg BID Edoxaban 60 mg QD At least 3 months Rivaroxaban 15 mg BID X 3 weeks, then 20 mg QD Apixaban 10 mg BID X 1 week, then 5 mg BID Single drug approach At least 3 months *or UFH or fondaparinux # with food At least 3 months Drug Shared Decision Making with Patients Considerations for selection of an anticoagulant regimen Parenteral lead-in Switch or dose deescalation Dosing frequency Renal elimination Interactions Adverse effects Dabigatran BID ++++ Few MI, GIB, dyspepsia Rivaroxaban N/A BID x Diet GIB days, then once daily (TAKE WITH FOOD) Apixaban N/A BID + Few N/A Edoxaban Once daily ++ Few N/A Warfarin N/A Once daily N/A Drug, diet, disease 2X MB 3X ICH, FB FB= fatal bleed; GIB= gastrointestinal bleed; ICH= intracranial hemorrhage; MB= major bleed; MI= myocardial infarction; 4

15 This Advanced is what we re afraid of PE therapies beyond anticoagulation for severe PE Pulmonary Embolism Akhilesh K. Sista, MD in 2015 Associate Professor and Section Chief, Division of Interventional Radiology NYU-Langone School of Medicine Massive 25-65% mortality (ICOPER, MAPPET) Submassive Low-risk 3% mortality (Jaff Circ 2011) 5% decompensation (PEITHO) <1% mortality (Jaff, Circ 2011) Massive Rescue Submassive Prevent mortality and hemodynamic decompensation (?) Low-risk Prevent progression to above (AC) 1

16 Intravenous thrombolysis Thrombolytics contraindicated Thrombolytic failure Alternative to thrombolysis preferred Rescue Surgical Embolectomy Catheter Directed Therapy CATHETER THERAPIES 2

17 Initial pulmonary angiogram Post Cleaner pictures Radiology Case Feb; 8(2):

18 FlowTriever Indigo Cat8 4

19 Submassive PE 5

20 Massive Rescue Submassive Low-risk Prevent mortality and hemodynamic decompensation, and long-term disability(?) Prevent progression to above (AC) ICOPER (1999) alerted the world to RV dysfunction PEITHO the trial to answer all uncertainty? 6

21 Systemic thrombolysis has a questionable risk-benefit profile in patients with submassive PE Intravenous thrombolysis Prevention Surgical Embolectomy Catheter Directed Therapy Physiologic rationale for intra-clot delivery of tpa Uflacker, R. Interventional Therapy for Pulmonary Embolism JVIR 12: (2001) 7

22 What is the rationale for treating submassive PE with infusion catheters alone? Uflacker, R. Interventional Therapy for Pulmonary Embolism JVIR 12: (2001) Nakazawa et al., Br. J Radiol, 2008 Main PA systolic pressure = 60mmHg. 8

23 Main PA systolic pressure=41 mm Hg 9

24 Prospective CDT trials PERFECT 100 ULTIMA CDT reduced RV/LV ratio to a greater extent than heparin at 24 hours* SEATTLE II: CDT is not risk free, but there were no intracranial bleeds* Clinical outcomes* N = 150 Mean length of stay ± SD, days 8.8 ± 5 In-hospital death, n (%) 3 (2) 30-day mortality**, n (%) 4 (2.7) Serious adverse events due to device, n (%) 2 (1.3) Serious adverse events due to t-pa, n (%) 2 (1.3) IVC filter placed, n (%) 24 (16) Major bleeding within 30 days**, n (%) GUSTO moderate** GUSTO severe** 17 (11.4) 16 (10.7) 1 (0.7) Intracranial hemorrhage, n (%) 0 (0) Courtesy of Gregory Piazza, M.D. 10

25 860 patient meta-analysis: reinforces efficacy and small but present bleeding risk of CDT Catheterization and Cardiovascular Interventions 89: (2017) Catheter-directed thrombolysis is efficacious in patients with submassive PE, but we need more data Trial Endpoint N Incidence MOPPETT Echo (pulm HTN) 60 57% Systemic lytic comparison? Yes -- Lower incidence in lytic patients Kline et al. Echo (pulmonary pressure elevation) % Yes No lytic patients had an increase in their estimated PA pressure Stevinson et al. 6MWD or NYHA>1 or RVD % TOPCOAT Exercise intolerance or low perception of wellness 43 28% Yes better composite outcome in lytic patients Sanchez et al. NYHA> % 11

26 Should catheterdirected thrombolysis be routinely used in the setting of submassive PE? Pulmonary Embolism Thrombus Removal with Catheter-Directed Thrombolysis: PE-TRACT RCT of CDT vs. No-CDT in the setting of submassive PE Long-term and short-term clinically relevant outcomes, important to patients and providers Inclusion and exclusion reflect clinical practice 414 patients 30 sites-50 sites 12

27 CTEPH: What is it? How Common? How to Treat? William R. Auger, MD Director, CTEPH Program University of California, San Diego What is CTEPH? Acute Pulmonary Embolus Incomplete resolution Loss of pulmonary vascular bed Progressive pulmonary hypertension Right heart failure Video courtesy of Fabio Jatene MD CTEPH Epidemiology: How Common Is It? Author Year Patient Number Incidence Marti % Dentali % Otero % Ribeiro % Sanchez % Korkmaz % Pengo % Surie % Miniati % Becattini % Klok % Poli % 1

28 Incidence of CTEPH Ende-Verhaar et al. Eur Resp J publications; meta-analysis Unprovoked PE, Recurrent PE.risk factors for CTEPH CTEPH dx w/o RHC overestimates incidence Post PE Syndrome Spectrum of disease from Acute to Chronic Klok et al. Blood Reviews 2014; 28:221 Risk Factors for CTEPH Patients with known PE VTE History History recurrent VTE Unprovoked PE RV dysfunction at PE diagnosis Persistent PH after treatment Thrombus burden Symptoms > 2 weeks at acute PE presentation Age > 60 years Klok et al. J Thromb Haemost 2016; 14:121 Pengo et al. N Engl J Med 2004; 350:2257 2

29 Acute PE to CTEPH: Medical Risk Factors Malignancy VA shunt, Infected intravascular device Thyroid replacement CTEPH Splenectomy Non-Blood group O Chronic inflammatory states Bonderman et al. Eur Resp J 2009; 33:325 Evaluation for CTEPH Disease Suspicion 1) Acute PE patients with persistent CP symptoms after 3 months of anticoagulation 2) ALL patients with pulmonary hypertension 3) Unexplained exertional dyspnea with or without history of thromboembolic event Screening for CTEPH Echocardiogram: detection of PH/RV size and function + Lung V/Q Scan: detection of perfusion defects Confirming CTEPH CT Angiography Pulmonary Angiography MRA/CMR CTEPH Diagnosis CTE Location PH Medical Therapy for Inoperable/Non-surgical CTEPH Pulmonary Thromboendarterectomy Balloon Pulmonary Angioplasty 3

30 Galiè et al. ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension EHJ

31 Updates in Pulmonary Embolism: Where are we in 2018 May 9 th, 2018 A Challenging PE case: would you do? Soophia Naydenov, MD, FCCP Associate Professor of Internal Medicine Saint Louis University School of Medicine Division of Pulmonary, Critical Care and Sleep Medicine soophia.naydenov@health.slu.edu Disclosure None A Challenging PE case A 79 year old female with history of SAH 4 years prior s/p endovascular coil embolization and VP shunt, seizures, hypertension who presents with AMS and shortness of breath. Per family she is mumbling and appears confused for the last few days PMH: HTN, SAH, seizure, VP shunt,kyphosis. Allergy: NKDA Family Hx: Not pertinent Social Hx: 50 packed year tobacco use ROS: Limited due to confusion but denies any complaints except cough 1

32 A Challenging PE case Laboratory Data Troponin ng/ml (Normal <0.032) BNP 787 pg/ml (Normal <100) Lactic acid 3.3 mmol/l (Normal 2.2) EKG Sinus tachycardia 2

33 3

34 What Echocardiogram would you do? A. Unfractionated heparin and observe B. Low molecular heparin and observe C. Systemic thrombolysis with 50 mg or 100 mg tpa D. Surgical embolectomy E. Anticoagulation + Catheter directed thrombolysis F. Anticoagulation + Catheter thrombectomy (mechanical) 79 F with high risk sub-massive PE given her elevated BNP, troponin and RV strain Wood, K. E. Chest 2002;121: A Challenging PE case UFH LMWH If deteriorates and not meet criteria for massive PE AC CDT Surgical options tpa ½ dose Not at this time If deteriorates and meets criteria for massive PE 4

35 A Challenging PE case 79 F with high risk sub massive PE given her elevated BNP, troponin and RV strain Anticoagulation HR and RR 2L O2 5L O2 Discussion & Decision A Challenging PE case UFH LMWH If deteriorates and not meet criteria for massive PE AC CDT Surgical options tpa ½ dose Not at this time If deteriorates and meets criteria for massive PE 5

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37 A Challenging PE case 79 F with high risk sub-massive PE given her elevated BNP, troponin and RV strain UFH LMWH If deteriorates and not meet criteria for massive PE AC CDT Surgical options tpa ½ dose Embolectomy and drainage of pericardial fluid If deteriorates and meets criteria for massive PE Embolectomy 7

38 A Challenging PE case Conclusion Clinically improved 11 days LOS DC to rehab Thank you A Challenging PE case OSH course: 49-year-old male patient presents to an OSH with shortness of breath and left sided pleuritic chest CT PE was done Elevated BNP, Troponin, RV strain on echo RX: Underwent Catheter directed thrombolysis (15 hours/10 mg) Improved clinically 2 days later symptoms recurred Repeat CT PE showed: No change 8

39 A Challenging PE case Transferred PMH: VTEs, IVC filter, Factor V Leiden mutation Social Hx: Never smoker HR , BP 134/72, RR 24, 89-90% on 6L BMI 28 kg/m2 Lab data: BNP 1410 pg/ml(< 100) Troponin I (<0.049 ng/ml), lactic acid normal 1.6 OSH 9

40 Echocardiogram OSH Repeat echo 20 days apart: RV: LV 1.1; Hypokinesis of RV free wall; EF 45-50% A Challenging PE case What Echocardiogram would you do? A. Unfractionated heparin and observe B. Low molecular heparin and observe C. Systemic thrombolysis with 50 mg or 100 mg tpa D. Surgical embolectomy E. Anticoagulation + Catheter directed thrombolysis F. Anticoagulation + Catheter thrombectomy (mechanical) 10

41 Discussion and Decision Submassive/Intermediate risk PE High risk (elevated biomarkers and RV strain) Challenges: Underlying chronic clot Recent catheter directed thrombolysis (within 3 days) Failure of therapy Long term anticoagulation CDT IVC filter Intervention Follow Up PA pressure 70/26 (41) OSH: PA 74/25 (46) Before and after BEFORE: PA pressure 70/26 (41) AFTER: 52/29 (37) 11

42 Before and after PE Clinic Follow Follow Up 6 Up month Very symptomatic Dyspnea Tachycardia HR in the 115 with 6MW 155 with saturation in the upper 80s 12

43 RHC HEMODYNAMIC FINDINGS: Measurements: Ao: 102/63/78 mmhg LV: 98/20 mmhg RA: 14 mmhg RV: 46 / 15 mmhg PA: 50 / 32/ 38 mmhg PCWP: 20 mmhg Calculations: CO: 4.7 L/min CI: 1.9 L/min/m2 SVR: 1088 dynes sec/cm5/m2 PVR: 3.8 Wood units TPG: 18 mmhg DPG: 12 mmhg Wedge pressure: 20 DPG: 12 TPG: 18 PVR: 3.8 wu 13

44 49 year old with recurrent VTE events CTEPH rx PTE surgical evaluation is underway 14

45 How to Develop a PERT Program Victor F Tapson, MD, FCCP, FRCP Cedars-Sinai Medical Center Los Angeles, CA USA NA-EKO MAY 2017 Relevant Financial Disclosures: Previous 12 months Affiliation/Financial Interest Grant/Research Support Consultant Lecture Honoraria Name of Affiliated Organization Bayer, Janssen, BiO2, Portola, EKOS/BTG, Daiichi Bayer, Inari,Janssen Janssen, BTG/EKOS Corporation* Royalties None *Lecture honoraria are paid to Cedars-Sinai What is a Pulmonary Embolism Response Team? A multidisciplinary team led by a group of physicians and other health-care professionals that has ability to: and diagnosis! Rapidly assess and provide comprehensive treatment of acute PE. Process and consider full range of medical, surgical, and endovascular therapies. Provide long-term follow up for patients with acute PE post discharge. 1

46 What are Treatment Options? Anticoagulation Unfractionated heparin Low molecular weight heparin Direct thrombin Inhibitors Factor Xa inhibitors Synthetic pentasaccharide Xa antagonist Warfarin Thrombolytic Therapy Systemic (full dose/ lower dose) Catheter-directed therapy Mechanical IVC filter Catheter-directed therapy Extracorporeal support- RVAD, ECMO, Impella Who Do You Need on Your Team? Depends on your institution Pulmonary & critical care Emergency department Diagnostic radiology Interventional radiology Interventional cardiology Emergency medicine Hematology Cardiothoracic surgery Cardiothoracic anesthesia Vascular medicine Vascular surgery Clinical pharmacy / Pharmacologists Nursing Who Will Utilize a PERT? Emergency Medicine All in patient medicine services Hospitalists, IM, subspecialties All surgical services, Ob-gyn All ICUs Operating room Referring hospitals Outpatient clinics 2

47 Attributes of a PERT To respond quickly To provide best therapeutic options available for each patient Evidence-based recommendations whenever possible To offer multidisciplinary input To coordinate care among services involved in management of PE To develop protocols for full range of therapies available To collect data including long-term follow up How do you get organized and form a team? Someone needs to take ownership Can be several individuals Determine who is interested and who is capable / available Multispecialty! Meet regularly (monthly?) Schedule? 3

48 Duke University Medical Center Model 1990s Acute massive or extensive PE suspected / diagnosed I was paged Anticoagulate with IV heparin ASAP Reviewed VQ or CTA, saw patient, determined plan Anticoagulation contraindicated? To IR for IVCF IV thrombolysis SK? UK? tpa? I would follow as inpatient. I would see in clinic or followed in hematology clinic. IV thrombolysis needed? Bleed risk? Bleeding risk? HIT? Thrombotic storm? Catastrophic APLA? Hematology Contraindicated? A few CT surgeons willing to do acute embolectomy Catheter-directed thrombolysis? Pulmonary fellows Gabe Lipshutz, MD (IR) Nursing, Pharmacy, ED, Other key personnel Jon Steinberger, MD (IR) Cedars-Sinai (and Duke) Model 2018 Acute massive or extensive PE suspected / diagnosed 3-CLOT is dialed to page pulm /CC fellow 4

49 Cedars-Sinai (and Duke) Model 2018 Acute massive or extensive PE suspected / diagnosed 3-CLOT is dialed to page pulm /CC fellow Stable patient Pulmonary fellow calls ED or team requesting consult: Cedars-Sinai (and Duke) Model 2018 Acute massive or extensive PE suspected / diagnosed 3-CLOT is dialed to page pulm /CC fellow Stable patient Pulmonary fellow calls ED or team requesting consult: High-risk or concerning intermediate-risk patient? Rapid assessment of CTA/VQ, echo, trop, BNP, leg US, other data. Sees patient. Pulmonary attending called immediately Pulmonary attending called after evaluation completed Cedars-Sinai (and Duke) Model 2018 Acute massive or extensive PE suspected / diagnosed 3-CLOT is dialed to page pulm /CC fellow Stable patient Pulmonary fellow calls ED or team requesting consult: High-risk or concerning intermediate-risk patient? Rapid assessment of CTA/VQ, echo, trop, BNP, leg US, other data. Sees patient. Pulmonary attending called after evaluation completed Other PERT team members: -CT surgery -IR Sick patient -I Cardiology requiring -Hematology intubation? IR? -CT anesthesia Pulmonary attending called immediately Treatment plan made, or Treatment plan made, or 5

50 Cedars-Sinai (and Duke) Model 2018 Acute massive or extensive PE diagnosed 3-CLOT is dialed to page pulm /CC fellow Stable patient Pulmonary fellow calls ED or team requesting consult: High-risk or concerning intermediate-risk patient? Rapid assessment of CTA/VQ, echo, trop, BNP, leg US, other data. Sees patient. Pulmonary attending called after evaluation completed Other PERT team members: -CT surgery -IR Sick patient -I Cardiology requiring -Hematology intubation? IR? -CT anesthesia Pulmonary attending called immediately Treatment plan made Treatment plan made Patient scheduled for f/u in PERT clinic (Pulmonary) Clinical Trials!! Diagnosis of acute PE in the ICU Catheter-directed therapy of acute PE Determination of PE severity by novel methods Follow up after hospitalization (Post-PE syndrome? CTED? CTEPH?) Novel echocardiographic techniques in acute PE Novel thrombolytic agents in acute PE PERT-related research! The PERT data base including quality assurance! Does PERT affect treatment outcomes? Do multidisciplinary meetings affect decision making? Is there an optimal PERT paradigm? 6

51 Operational Approach Chest Nov;144(5): doi: /chest A multidisciplinary pulmonary embolism response team. Kabrhel C, Jaff MR, Channick RN, Baker JN, Rosenfield K. GoToMeeting 12 weeks 30 patients 25 confirmed PE Median time to PERT meeting = 57 minutes Operational Approach Hospital Practice Feb;42(1): doi: /hp The Massachusetts General Hospital Pulmonary Embolism Response Team (MGH PERT): Creation of a Multidisciplinary Program to Improve Care of Patients With Massive and Submassive Pulmonary Embolism. Provias T 1, Dudzinski DM, Jaff MR, Rosenfield K, Channick R, Baker J, Weinberg I, Donaldson C, Narayan R, Rassi AN, Kabrhel C. PERT Database BCRI Affiliation! Web-based HIPAA compliant 16 forms Up to 347 variables Prospective data entry Scalable 7

52 The State of the Consortium Future Plans - Goals for next year and beyond Public awareness Patient and provider education Regional symposia Website update Database Research and QA (BCRI) The FDA Our committees Grant process Contributors Kenneth Rosenfield, MD Section Head, Vascular Medicine and Intervention, Chairman, STEMI & Acute MI Quality Improvement Committee Robert Lookstein, MD Vice President Multidisciplinary! 8

53 Board of Directors John "Jerry Bartholomew, MD Robert Maholic, DO Kenneth Rosenfield, MD* Charles Ross, MD, FACS David Slosky, MD George Davis, PharmD, BCPS James Horowitz, MD Brent Keeling, MD Jana Montgomery, MD Multidisciplinary! Jay Giri, MD, MPH Christopher Kabrhel, MD, MPH Rachel Rosovsky, MD 9

54 CONCLUSIONS: Acute PE is a deadly disease PE expertise crosses many subspecialties An organized approach to acute PE will facilitate care Find out who is interested and necessary at your institution Meet and iron out the kinks Consider a call schedule If your hospital is small, you can still have an organized approach Consider discussion with larger institution re when consulting / transfer may be needed Join the PERT Consortium! 10