- 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 - ECG: - 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 - Echocardiography: - PE provoked RVD is defined by RV dilatation (a requirement) with or without septal deviation or RV hypokinesis - 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: http://www.cmcedmasters.com/ultrasound.html
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