Pulmonary Embolism Response Team (PERT) A Multidisciplinary Approach For Treatment of Acute Pulmonary Embolism

Thomas M. Todoran, M.D., M.S. Assistant Professor of Medicine Medical University of South Carolina Interventional Cardiology Director of Vascular Medicine

Presenter Disclosures Thomas M Todoran (1) The following relationships with commercial interests related to this presentation existed during the past 12 months:

No relationships to disclose

Background • Pulmonary embolism (PE) is responsible for more than 300,000 deaths annually • An estimated 600,000 patients develop symptomatic PE annually • Mortality rate in the first three months following a diagnosis of PE ranges from 15-18% • The overall mortality rate has not improved significantly in the past three decades

Clinical Presentation of Pulmonary Embolism Non Massive Low Risk Submassive Intermediate Risk RV dysfunction Biomarkers Massive High Risk

et al.

Therapeutic Alternatives for Treatment of Pulmonary Embolism Anticoagulation • UFH – Continuous Intravenous – Full-dose Subcutaneous

• • • • • • • •

LMWH Direct Thrombin Inhibitors Factor Xa Inhibitors Coumadin Warfarin Apixaban Rivaroxaban Dabigatran

Thrombolytic Therapy • Catheter-Directed • Systemic Mechanical Therapy • • • • •

IVC Filer Surgical Thrombectomy Mechanical fragmentation Aspiration ECMO et al.

Data Gap: Submassive PE

GAP

Sista et al. Vascular Medicine 2015

Guidance for Treatment of Acute Pulmonary Embolism

C Kearon et al., Chest 20121; MR Jaff et al., Circ 20112; S Konstantinides et al., Eur Heart J 20143

Thrombolysis Guidelines: Sub-massive Pulmonary Embolism ESC 3

ACC/AHA2

ACCP1

C Kearon et al., Chest 20121; MR Jaff et al., Circ 20112; S Konstantinides et al., Eur Heart J 20143

Catheter-Based Procedures: Sub-massive Pulmonary Embolism ESC 3

ACC/AHA2

ACCP1

C Kearon et al., Chest 20121; MR Jaff et al., Circ 20112; S Konstantinides et al., Eur Heart J 20143

Surgical Embolectomy: Sub-massive Pulmonary Embolism ESC 3

ACC/AHA2

ACCP1

C Kearon et al., Chest 20121; MR Jaff et al., Circ 20112; S Konstantinides et al., Eur Heart J 20143

Predictors of Mortality from PE

Massive

Sub-massive High Risk

Sub-massive Low Risk

C. Becattini and G. Agnelli. Thromb Haemost 2008

Risk for Mortality from PE

European Heart Journal 2014

PESI Score

European Heart Journal 2014

Treatment Algorithm: ESC Guidelines

European Heart Journal 2014

Treatment Algorithm : ACC/AHA Guidelines

M Jaff et al. Circulation 2011

Pulmonary Embolism: Previous Paradigm …..Chaos ICU ED Floor

Outside Hospital

Heparin or tPA

Catheter Procedure

Vascular Medicine

Surgical

Cardiac Surgery

Hematology

Thoracic Surgery

Pulmonary

Vascular Surgery Cardiology

Radiology et al.

PE: A Clinical and Logistic Quandary • Prevalent and potentially life-threatening cardiovascular condition that may be difficult to diagnosis • Third most common cause of death in the United States, and yet does not have a robust clinical trial evidence base to guide appropriate therapeutic strategies • Treatment is generally guided by severity yet risk stratification classifications are not universally applied and differ between evidence-based clinical practice guidelines • Multiple specialties diagnose and treat

• Some acute pulmonary embolisms mandate urgent intervention compounds these issues

Rationale for PERT: Heart Team • Minimize fragmented decision making to improve coordination of care • Facilitating joint and shared decision making among different medical care stakeholders • Improve timeliness and consistency of decisions when multiple providers are involved • Allow more intricate patient-centered treatment plans to be developed DR Holmes et al. JACC 2013;

Serruys et al. NEJM 2009

P Kolh et al. European Journal of Cardio-thoracic Surgery 2010

RA Nishimura et al. Circulation 2014

Rationale for PERT: Rapid Response Systems • Rapid response teams were created to improve recognition and response to deterioration of hospitalized patients as a means to prevent cardiopulmonary arrest and death

• Components of RRS • Specific criteria for activation and a notifying system for activating the response team (“afferent limb”) • The response team (“efferent limb”) • Administrative infrastructure • Continued quality improvement BD Winters et al. Ann Intern Med 2013

Rapid Response Systems Reduce Cardiac Arrest

BD Winters et al. Ann Intern Med 2013

PERT: Mission • To Improve patient outcomes with a collaborative, multidisciplinary urgent consult of often complex patients presenting with acute pulmonary embolism

et al.

PERT: Objectives • Respond expeditiously to treat patients with massive and sub-massive PE

• Provide individualized care of patients offering the best therapeutic options for each respective patient • Leverage input from a multidisciplinary team of experts • Coordinate among services involved in care of patients with PE • Develop protocols for full range of therapies et al.

Provias et al. Hospital Practice 2014

Kabrhel et al. Chest 2016

Kabrhel et al. Chest 2016

MUSC PE

Acute Pulmonary Embolism (843) 792-2300

MUSC Physician ED Inpatient Service ICU

Outside Physician

(843) 792-3306

Patient name Location Call Back Number

PERT

On Call PERT Fellows

History Physical examination PE Risk Bleeding risk

CTA Echocardiogram ECG Troponin BNP CBC, PT/INR, BMP Lower Extremity US

Assess the patient Assimilate the data Risk stratification

WebEx Meetings

Web-based Conference Call Interventional Cardiology

Pulmonary Critical Care

Cardiovascular Medicine

Vascular Medicine

Multidisciplinary Discussion Emergency Medicine

Radiology

Hematology

Cardiothoracic Surgery

Treatment Plan

Send “Meeting Number” via page

MUSC PERT • Since January 2015 • Co-managed forty patients with acute pulmonary embolism • Pulmonary Embolism Category – Sub-massive 87.5% – Massive 12.5%

• Treatment – Anticoagulation 49% – Systemic tPA 15% – Catheter-Directed Thrombolysis 36%

• Length of Stay – 10 days

• In-hospital Mortality – 7.5%

et al.

Pert Consortium

http://pertconsortium.org/

Pert Consortium 2016 Meeting

Pert Consortium: Data Collection • • • • • • •

Web-based HIPAA Compliant 16 Forms Up to 347 variables Prospective data entry Scalable Currently 17 sites

http://pertconsortium.org/

Summary • Optimal management of pulmonary embolism is still evolving

• There is a need to expand the body of scientific literature on the treatment of acute pulmonary embolism • New era of heightened awareness about the need for coordinated interdisciplinary approach to complex, lifethreatening problem • PERT Consortium will allow exchange of ideas and information related to care of patients with pulmonary embolism et al.

Case • 67 year old F transferred from outside hospital where she was hospitalized for a week being treated for pneumonia • Previously healthy without significant PMH

• Hypoxic with O2 Sats 88% on NR, RR 32 • BP 160/87 mmHg, HR 120 bpm • Labs remarkable for elevated troponin and BNP et al.

CTA

et al.

Echocardiogram McConnell Sign

et al.

Echocardiogram RV Size and Function Tricuspid Annular Plane Systolic Excursion (TAPSE)

Normal RV Diameter Basal 16 mm

RV Dysfunction