By Parth Rali, MD, Director, Pulmonary Embolism Response Team, Temple University Hospital
Pulmonary embolism (PE) is the third most common cardiovascular cause of inpatient hospital death in the United States, and the prevalence of PE risk factors—including surgery, obesity, a sedentary or immobile lifestyle, and advanced age—is increasing. Immobile lifestyle is a big concern in the COVID-19 era, where home isolation and social distancing are highly recommended.
Many PE fatalities can be prevented if the condition is quickly and appropriately treated, yet decision-making has become more complex due to new options and controversy about appropriate care for different patient groups. Establishing pulmonary embolism response teams (PERT) within hospitals and health systems can help improve decision-making through rapid convening of specialists in all necessary areas, and can help ensure access to the most up-to-date treatment options by focusing institutional resources. Pulmonary embolism has been seen in up to 50% of ICU admissions based on emerging data from the COVID-19 patient population.
Treatment is often decided based on patient stratification, yet risk assessment itself is difficult. Not only can a patient’s condition progress quickly, but there are multiple, differing sets of standards and guidelines developed by organizations such as the American Heart Association and the European Society of Cardiology. This makes it even more important to have a platform for quick, consensus-based decision-making at the health system level. Recently, the American College of Chest Physicians has released COVID-19 venous thromboembolism (VTE) guidelines that provide some insight into VTE management in the COVID era.
Treatment options also evolve quickly. For example, patients with massive, or high-risk, PE need aggressive treatment, yet thrombolytic drugs may limit treatment options by increasing the risk of major bleeding. A major recent advance in this area is the use of interventional approaches, which allow for more concentrated application of thrombolytics (and often a smaller overall dose). Many types of infusion catheters are now available and more are under investigation. For example, the Bashir Endovascular Catheter (BEC), co-created by Temple’s Riyaz Bashir, MD, FACC, RVT, for which Temple recently participated in an early feasibility study, and for which a large-scale trial (RESCUE) is expected to start later this year. Percutaneous mechanical embolectomy, an option for patients at high risk of bleeding, is also now available through Temple’s interventional radiology team.
Temple PERT was formed in 2017, and has been activated more than 500 times as of March 2020. A designated pulmonary care fellow responds to all incidences of PE, conducts an exam, and acquires necessary patient information, then convenes the on-call PERT. Depending on the severity of the case, a multidisciplinary team of physicians may assemble in person or via conference call, including pulmonary care physicians, interventional radiologists, and cardiologists. Temple’s PERT provides access to the full range of FDA-approved thrombolytic drugs and interventional tools (including percutaneous mechanical embolectomy); active clinical research programs around PE; and—perhaps most importantly—experts systemwide who understand all of the options and can make informed decisions about how to move forward. Follow-up care is also prioritized, within two weeks of discharge depending on the severity of the patient’s condition; we have seen more than 150 such patients in the past year at the Temple Lung Center.
Temple Health is a founding member of the National Pulmonary Embolism Response Team Consortium, which advances the science and practice of PE care, including through the development of care guidelines and standards. Our local PERT team members, residents, and fellows are actively participating in various committees, presentations, and academic activities through the PERT Consortium™.
If you’re in the Philadelphia region and need a quick and coordinated response on a pulmonary embolism case, call 215-707-TRAN and ask for the Temple Pulmonary Embolism Response Team. To learn about participating in our clinical research and trials regarding PE therapies, contact 215-707- 1359. For the latest guidelines on PE care and forming a PERT, explore the PERT Consortium™ at pertconsortium.org. ■