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Management of intermediate and high risk pulmonary embolism (aka submassive/massive PE)

Pulmonary embolism is probably discussed far more than is truly necessary. It receives more attention than almost any other pathology. We endlessly debate the best algorithms for diagnosis. We add new decision tools almost yearly. However, if there is one aspect of pulmonary embolism that might be under-discussed it is the management of massive and submissive PEs. “Submassive PE” encompasses a much larger and much more heterogeneous group of patients, which probably explains why there is still so much confusion and debate about the best approach to these patients. Hopefully future research will do a better job risk stratifying within this group, because they are not all created equal. For now,…

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 Interventions for Intermediate-Risk Pulmonary Embolism

Large-bore mechanical thrombectomy was superior to catheter-directed thrombolysis in a randomized trial. For patients with intermediate-risk pulmonary embolism (PE) — evidence of right ventricular (RV) dysfunction without overt hypotension — guidelines recommend anticoagulation alone (Circulation 2019; 140:e774). However, when such patients receive anticoagulation only, they have a small but relevant excess short-term mortality risk

Articles of Interest

Acute Pulmonary Embolism: Management of Massive and Submassive Pulmonary Embolism

INTERMEDIATE-RISK PE (SUBMASSIVE PE) - Characterized clinically by absence of “overt” hemodynamic instability, although the clot burden on RV performance is significant enough to cause some degree of RV dysfunction. The mortality risk is 2-17% . Normotensive shock: Note that some patients with PE have a hyperadrenergic response; therefore, present initially with normo-hypertension.

Approach to Acute Intermediate-Risk Pulmonary Embolism

In this case, I would start low-molecular-weight heparin (LMWH) and then transition to a direct oral anticoagulant. Although both LMWH and unfractionated heparin (UFH) are good initial options for intermediate-risk acute PE, LMWH is probably preferred in this case due to the rapid mechanism of action, reliable bioavailability, and excellent safety.

Catheter‐directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism

Intermediate‐risk (submassive) APE represents 45% to 65% of APE cases, with a short‐term mortality rate of around 3%. Systemic thrombolysis is not recommended for this group, as major haemorrhagic complications outweigh the benefit. However, the people at higher risk within this group have a short‐term mortality of around 12%, suggesting that anticoagulation alone is not an adequate treatment. Identification and more aggressive treatment of people at intermediate to high risk, who have a more favourable risk profile for reperfusion treatments, could reduce short‐term mortality and potentially reduce post‐PE syndrome.

Intermediate Risk Pulmonary Embolism Risk Stratification, Management and Algorithm

PE severity exists on a spectrum, ranging from low-risk cases to cardiac arrest. Patients who fall in the intermediate-risk category are particularly challenging because they represent a heterogenous group with varying degrees of severity and risk for clinical deterioration.

Intermediate-Risk Acute Pulmonary Embolism

In the assessment and management of patients with acute symptomatic pulmonary embolism (PE), prognostic information helps to guide therapeutic decision-making. PE is classified as low, intermediate, or high risk according to the risk for in-hospital or 30-day mortality, based on the simplified Pulmonary Embolism Severity index, biomarkers, and right ventricle (RV) assessment. Hemodynamically stable patients with both evidence of RV dysfunction (by echocardiography or CT pulmonary angiography and elevated troponin levels) are classified into the intermediate-high-risk category. Patients in whom RV is normal at imaging tests or who have normal cardiac biomarkers levels formed the intermediate-low-risk group

Intermediate-Risk Pulmonary Embolism: A Review of Contemporary Diagnosis, Risk Stratification and Management

PE is divided into three risk categories: low risk, intermediate-risk, and high risk. In terms of initial therapeutic choice and long-term management, intermediate-risk (or submassive) PE remains the most challenging subtype.

Management of intermediate high-risk pulmonary embolism: a single-center retrospective study

This study supports guidelines advising against routine use of RT for intermediate high-risk PE unless as rescue therapy. No mortality rate reduction or secondary outcome benefits were observed, highlighting the need for consistent management protocols and further research on therapeutic approaches for intermediate high-risk PE.

Risk Stratification and Management of Intermediate-Risk Acute Pulmonary Embolism

Pulmonary embolism (PE) is the third most common cause of cardiovascular death and necessitates prompt, accurate risk assessment at initial diagnosis to guide treatment and reduce associated mortality. Intermediate-risk PE, defined as the presence of right ventricular (RV) dysfunction in the absence of hemodynamic compromise, carries a significant risk for adverse clinical outcomes and represents a unique diagnostic challenge. While small clinical trials have evaluated advanced treatment strategies beyond standard anticoagulation, such as thrombolytic or endovascular therapy, there remains continued debate on the optimal care for this patient population.

Submassive & Massive PE

RV dilation is a prerequisite for either submassive or massive PE. Risk stratification in PE is extraordinarily challenging. Being thorough is good, but it is also important to avoid “counting” the same risk factor multiple times (e.g., if the right ventricle is severely dilated on CT and also dilated on echocardiogram, then echocardiogram doesn't provide any new information).