Fellow UMass Memorial Medical Center Worcester, Massachusetts
Introduction: The management of intermediate risk pulmonary embolism (PE) remains controversial. Current guidelines recommend treating with systemic anticoagulation alone. With right heart strain, however, these patients are at risk of hemodynamic decompensation.
Description: A 30 year old male, who was a Jehovah’s Witness, presented after syncope with head strike and was found to have bilateral pulmonary emboli. There was evidence of right heart strain by CT and elevated troponin I. He was hemodynamically stable and in conjunction with head trauma the decision was made to start a heparin drip. Over the course of the night, his heart rate was increasing and troponin rose from 0.13 to 1.55 ng/mL. He did have an intermittent decrease in blood pressure to 95/47, however, his systolic blood pressures remained stable around 101-122. He had another syncopal event with head strike. After three negative head CTs and a multidisciplinary discussion, he was treated with alteplase at a reduced dose of 50 mg (10 mg bolus, followed by 40 mg over two hours). During treatment he did develop an expanding hematoma on his forehead, however, no intervention was needed. He remained hemodynamically stable without any further syncopal events. He was discharged on warfarin.
Discussion: PE ranks high among causes of mortality and about 10% die within the first three months. Right ventricular failure is the primary cause of death. Patients with intermediate risk PE have evidence of right heart strain, however, are hemodynamically stable. Based on current evidence the guidelines recommend treating with systemic anticoagulation alone. The risk of serious bleeding with systemic thrombolysis has been shown to outweigh the benefits in this patient population. As evidenced by this case, some of these intermediate risk patients will decompensate and may require further intervention. This case could suggest that reduced dose thrombolysis may be as beneficial as current standard dosing regimens with less risk of bleeding. There is not consensus currently on how to manage these patients, however, this is an important population where more data is needed. Current studies should focus on reduced dose thrombolysis and catheter directed therapies to find ways to manage patients with intermediate risk PE more safely and effectively.
