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CENTRAL PULMONARY EMBOLISM: TO LYSE OR NOT TO LYSE?

Winthrop University Hospital, Mineola, NY

PURPOSE: To review the presentation and management of patients with central pulmonary embolism (PE) at a University Medical Center. Central PE was defined as clot in the main pulmonary artery or multiple lobar branches.

METHODS: We retrospectively reviewed the records of consecutive patients with central PE detected by CT pulmonary angiography (CTPA). We recorded demographic data, clinical findings at presentation, including heart rate, blood pressure, oxygen saturation, EKG findings, as well as echocardiographic and CTPA evidence of right ventricular dilatation. Treatment options, including thrombolysis, heparin, and inferior vena cava (IVC) filter were noted.

RESULTS: Nineteen adult patients with central clot on CTPA were identified. Mean age was 60 years(range 33 to 86) and 10 were females. All patients had evidence of right ventricular (RV) dilatation on CTPA (defined as a ratio of RV/left ventricular (LV)>1.0).Only 4 patients were hypotensive on presentation: 2 corrected with fluids; one had a cardiac arrest shortly after presentation and died in <12 hours; the other was ventilated and on pressors and received tissue plasminogen activator (tPA)with improvement in hemodynamics. Heart rate at presentation was >100/minute in 13 patients (73%). Hypoxemia was present in 13 (73%). Electrogradiographic changes of RV strain were present in 6 patients (32%): three of these patients received tPA.Ten patients also had deep vein thrombosis (DVT)and 8 received IVC filters in addition to anticoagulation. One patient died of underlying extensive malignancy. There were no episodes of recurrent PE prior to discharge.

CONCLUSION: Most patients with central clot were not hypotensive even with significant RV dilatation on CTPA, a finding associated with RV dysfunction. A similar rapid clinical resolution was seen in patients treated with either heparin or tPA and no patient required escalation of therapy due to clinical deterioration.

CLINICAL IMPLICATIONS: CTPA is a useful tool to detect RV dilatation. The presence of large central pulmonary emboli and RV dilatation alone on CTPA does not indicate the need for thrombolysis, as most patients improved rapidly with routine anticoagulation.

DISCLOSURE: Nimrita Dhanjal, None.