Review on the state of current knowledge on pulmonary embolism published in New England Journal of Medicine (NEJM)
The special feature,
co-authored by Dr. Susan R. Kahn and Dr. Kerstin de Wit, aims to help front
line clinicians better diagnose, treat, and manage a common condition with many
repercussions and the potential to be fatal for patients.
Pulmonary embolism (PE) is the most dangerous, and
potentially life-threatening, form of venous thromboembolism (VTE), in which a
blood clot develops in a large vein. PE occurs when a blood clot travels from
the legs to the lungs, causing an individual to experience stabbing chest
pains, coughing, difficulty breathing, and a rapid pulse. This affects an
average of 30,000 Canadian each year.
“While PE is a common condition, it is
often misdiagnosed and underdiagnosed as knowing which diagnostic test to use
and when is a major challenge,” says Dr. Susan R. Kahn, Senior Investigator in
the Centre for Clinical Epidemiology of the Lady Davis Institute at the Jewish General
Hospital (JGH), Director of the JGH Centre of Excellence in Thrombosis and
Anticoagulation Care (CETAC), and Canada Research Chair in Venous
Thromboembolism, lead author of the article. “In practice, it may be diagnosed
as some other problem, such as pneumonia, or physicians might not think the
patient could have PE and do a proper diagnostic test.”
Recovery from PE is associated with
complications such as bleeding due to anticoagulant treatment, recurrent VTE,
chronic thromboembolic pulmonary hypertension, and long-term psychological
distress. Furthermore, Dr. Kahn’s team previously showed that approximately
half the patients who receive a diagnosis of PE have functional and exercise
limitations one year later (known as post–pulmonary-embolism syndrome), and the
health-related quality of life for patients with a history of PE is poor,
making the timely diagnosis and expert management of PE crucial.
Dr. Kahn and co-author Dr. Kerstin de
Wit, a venous thrombosis and emergency medicine physician and researcher based at
the Kingston Health Sciences Centre, provide
a clinical overview of what is currently known about PE, its diagnosis,
treatment, management, and patient follow-up, using a case vignette.
The article contains many practical
points for clinicians, highlighting that:
- PE is a common diagnosis with many
repercussions, which has the potential to be fatal if not recognized and
treated appropriately. Untreated PE has a mortality rate approaching 20%;
- It is very important for physicians to
be familiar with one diagnostic approach, to know it very well, and to use it
systematically;
- Initial treatment is guided by
classification of the pulmonary embolism as high-risk, intermediate-risk, or
low-risk;
- Treatment
modalities and duration vary depending on patients’ medical conditions and
characteristics (i.e. cancer, advanced kidney or liver disease, pregnant women,
etc.)
The article reviews the latest research,
existing clinical practice guidelines and presents the main areas of
uncertainty that need to be addressed to ensure the optimal care and management
of patients with or at risk of PE.
“Whether a particular direct oral anticoagulant
– the standard of care – is preferable for the treatment of PE is not known at
this point,” Dr. Kahn exemplifies. “That is why we are currently enrolling
patients from CETAC in ongoing randomized trials that are assessing apixaban as
compared with rivaroxaban for the initial treatment of patients with venous
thromboembolism.”
Dr. de Wit will address another area of
uncertainty by leading in Canada an important multinational, randomized,
controlled trial to assess the efficacy and safety of a therapy involving a
reduced dose of thrombolytic medication in patients with intermediate-risk
acute PE. This trial will start in a few months and will be conducted at the
Jewish General Hospital/Lady Davis Institute as well.
“The good news is that blood clots are
preventable and treatable if discovered early,” says Dr. Kahn. “Although there
are many risk factors, with proper attention to prevention and treatment, we
can reduce the incidence and recurrence of VTE and its complications, such as
PE.” This emphasizes the importance of concerted efforts to guide and train
physicians— especially those working in high-risk settings such as primary care
offices, emergency rooms, inpatient medical and surgical wards and intensive
care units—and to educate the public at large and patients to ensure early
diagnosis.
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