The Approach to Massive Pulmonary Embolism

Massive pulmonary embolism (PE) is surprisingly common and is not necessarily heralded by dramatic symptoms or signs. The death rate from PE remains high, and the most common cause of mortality is recurrent PE, not cancer. Prevention of recurrent embolism with intensive anticoagulation remains the foundation of therapy. The Food and Drug Administration has approved use of the low molecular weight heparin enoxaparin for inpatient treatment of deep venous thrombosis (DVT) with or without PE as a "bridge'' to warfarin. However, in patients with massive PE, anticoagulation alone often does not suffice to prevent death or disability from chronic pulmonary hypertension. Impending hemodynamic instability due to massive PE and its attendant ominous prognosis can be detected by rapid identification of moderate or severe right ventricular failure (usually easily with transthoracic echocardiography). Successful treatment of overt cardiogenic shock, manifested by systemic arterial hypotension and tachycardia, is far more difficult than implementing a strategy that champions early intervention after the onset of right ventricular failure. Among patients with massive PE, thrombolysis and embolectomy (often performed in the interventional angiography laboratory) are being used with increasing skill and improved outcomes. Intensive pharmacologic therapy and mechanical support devices portend a new era of improved intensive and multidisciplinary management of these gravely ill patients.