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Pro-Con Debate: Cracking the Clot!

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Almost 300,000 deaths due to acute pulmonary embolism (PE) are reported annually. During Chest 2023, in a session on 'cracking the clot,' different treatment strategies, including anticoagulation, systemic thrombolysis, catheter-based therapies, and surgical embolectomy, were discussed in the pro-con debate form. 

Systemic thrombolytic therapy (ST/t-PA) for patients with acute pulmonary embolism may benefit patients with massive or high-risk PE, which happens in around 2% of cases, according to the latest data from the National Emergency Database Sample (NEDS). Unfortunately, almost 40–50% of the patients who may qualify or benefit from ST have either absolute or relative contraindications for t-PA. Those patients with contraindications may benefit from alternate reperfusion modalities, including catheter-directed therapies (clot retrieval/lysis) or surgical embolectomy in a few cases. However, that strategy should not include individuals suffering from hemodynamically stable intermediate-risk PE with right ventricular dysfunction. Based on the PEIHO trial, the largest randomized controlled trial for intermediate-risk PE, mortality at day seven and day 28 was not different in patients who received t-PA (thrombolysis) vs. those who didn't. The significant bleeding, including intracranial hemorrhage risk, was higher in patients treated with thrombolysis. One important point to note about the PEITHO trial is that the mortality in both arms was low, ranging from 2–3%. Finally, almost 40% of patients with acute PE are considered low-risk, hemodynamically stable, and without RV dysfunction on Echocardiography or CT. Those with a simplified pulmonary embolism severity (sPESI) score of 0. sPESI is a validated tool for risk stratification of patients of PE, which includes six variables and can be easily remembered by a mnemonic S-PEPSI as described below. 

SpO2 < 90% on room air

Pulse Rate > 110/min

Elderly patient > 80 Y

Pulmonary/Cardiac Disease Yes

SBP < 100 mm of Hg

Infiltration (Cancer) Yes

These low-risk PE patients, with an sPESI score of zero, usually can be treated with oral or systemic anticoagulation alone. Several of them can be discharged from the emergency department also. 

Dr. Dalal has no conflicts of interest to report.

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