Management of Acute Pulmonary Embolism

Dear Colleagues,

Acute pulmonary embolism is the third cardio-vascular disease for mortality after myocardial infarction and stroke. Pulmonary embolism is a part of venous-thromboembolic disease, with many other diseases and conditions behind the thrombotic process that can strongly influence the management of patients. Anticoagulant therapy is a cornerstone of treating acute PE; however, the intensity and duration of therapy need a personal approach with huge gaps in knowledge. Regarding acute PE management, the classical European Society of Cardiology model for the assessment of mortality risk is far from clinical needs, and there is room for many fine tunings here. For instance, should we have sex adjustment of the many cut-off parameters used for risk stratification, for instance, even for arterial systolic blood pressure cut-off for the high-risk determination? In clinical praxis, we feel that many patients with intermediate-high risk acute PE who have some high-risk features or do not improve on anticoagulation therapy alone could benefit from reperfusion therapy before hemodynamic deterioration. However, what is the best reperfusion therapy? Lower-dose systemic thrombolysis, lower-dose catheter-directed thrombolysis, catheter mechanical therapy, or surgical embolectomy. Additionally, how can we estimate the risk for bleeding in thrombolysis, which is the main obstacle to this treatment, and does the use of local thrombolysis with a low dose of thrombolytic drugs or mechanical reperfusion can prevent serious bleeding? The important questions are also how to prevent the late complications of acute PE, such as chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome. Are direct oral anticoagulant drugs better for this purpose? Do we need percutaneous intervention for patients with large thrombus burden, trying to reduce it in the subacute phase of PE? Oncology patients with acute PE need special consideration. Do we need special thromboembolic treatment for various malignant diseases since the pathophysiology of thrombosis in oncology patients might differ?

Prof. Dr. Slobodan Obradović
Guest Editor

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