- Hypotension: sustained or transient (<15minutes) with or without shock is considered high risk
- Largest and most challenging group of PE patients are normotensive
- Risk stratification options include evaluating co-morbidities and susceptibility to PE including cancer (metastatic or localized), cardiopulmonary disease and cardiac disease
- Clinical Scoring options include PESI and HESTIA which evaluated for comorbidities, AC bleeding risk and presence or absence of severe vital sign abnormalities.
- They notably do not incorporate any assessment of RVD.
- American Heart Association and European Society of Echocardiography guidelines prominently include RVD assessment with echo, cardiac biomarkers or CT RV LV ratio
- Right ventricle dysfunction is the common pathway to clinical deterioration and PE related death or cardiopulmonary disability.
- Methods of evaluating for RVD include:
- Pulse oximetry: <90% more severe, 90-94% moderate, >94% low risk
- moderate(tachycardia, S1Q3T3, or incomplete RBBB)
- more severe" inverted T waves V1-V3
- severe: bradycardia <40 bpm, RBBB, ST elevations, V1-V3 or aVR, T wave inversions II, III AVF
- Troponin I or T elevations as high as 7 fold increase in adverse events
- BNP/proNBNP >90, >900 limited specificity 5-7 fold increase in adverse events
- Both biomarkers elevated Odds ratio of 8.4
- Both biomarkers low death and short term serious adverse event
- PE provoked RVD is defined by RV dilatation (a requirement) with or without septal deviation or RV
- RV hypokinesis (with RV dilatation indicates more advanced RV dysfunction.
- Tricuspid regurg velocity limited use as worsened RV contractility can weaken the tricuspid
regurgitation to undetectable levels
- CT useful for diagnosis but also risk stratification looking for 1) clot burden but more important is
2) RV strain RV:LV ratio>1.0
- Low risk PE patients may be considered for brief observation and initial treatment or considered for outpatient anticoagulation
- Clinical scoring systems like PESI and HESTIA do not include any RVD assessments
- Low risk categorization by PESI scores may have RVD (as high as 35 % in one study) which gives a different risk categorization if AHA or ESC guidelines were used.
- Current version of ESC guidelines include RVD assessments mainly in non low risk PESI scoring however presence of RVD is not uncommon amongst those with low risk by PESI
- Some studies with low risk category by PESI and +RVD show no adverse outcomes, others show patient experience adverse outcomes.
See RVD assessment with Goal Directed Echocardiography tutorial on Compendium: