The most essential concern about PE is correctly triaging. Patients with shock have a high risk of death and quickly need systemic thrombolytics unless contraindications exist. Patients without signs of right ventricular dysfunction are low risk and can be treated with anticoagulation only.
Pulmonary emboli with some signs of right ventricular dysfunction but without shock are commonly called “submassive” and the ideal treatment plan for these patients is more difficult. Attached to this post are three excellent recent papers looking at routine thrombolysis for this patient population; unfortunately, they have conflicting results. The general conclusion is that the risks and benefits of thrombolysis in patients with submassive PE need to be judged on an individual basis.
Research in the triaging of patients with PE continues to be active but incomplete. The PESI and sPESI are the easiest scales to risk stratify; however, many patients will have additional information such as BNP, troponin, or ultrasound evaluation of the right ventricle that are more accurate and are not incorporated into these scales.
Primary catheter-directed thrombolysis has very limited poor research at this time and should only be utilized when contraindications to systemic thrombolysis exist. Poor early outcomes in DVT and CVA suggest that catheter-directed therapies should be approached with extreme caution.
The 2012 ACCP and 2014 ESC guidelines continue to be excellent references in the treatment of PE.