Dr Parth Rali Explains Challenges of Managing Intermediate-Risk Pulmonary Embolism

Parth Rali, MD, associate professor of thoracic medicine and surgery at Temple University's Lewis Katz School of Medicine, discussed the challenges of managing intermediate-risk pulmonary embolism (PE) and how risk stratification tools can help treat these patients.

Rali chaired a session on this topic at CHEST 2023. He also facilitated a panel discussion where he used real world cases to discuss the role of a multidisciplinary approach in post-PE follow up and how to manage the clinical pathways. This year at CHEST, Rali was recognized as a distinguished CHEST educator.

Transcript

What are some of the common challenges and limitations and managing intermediate-risk PE? How do you address them in your practice?

Let's take a step back. So, PE we kind of divide into 3 different categories, we divide into the low-risk, we divide into intermediate-risk, something which we call a gray zone, and then high-risk.

The treatment pathways for the high-risk PE and low-risk PE are well described, they’re well carved out. When it comes to the intermediate-risk PE, those are the people who are right between completely stable vs completely not stable, and that's where most of the research and interest is currently focused on.

Giving an example from a recent publication from last year, intermediate-risk PE describes close to 50% to 60% of patients presenting in United States, so it is kind of an area of concern. Luckily, at Temple, like many other great institutions, we have a multidisciplinary program of physicians who helps us navigate through the process of intermediate-risk PE. It’s an evidence based and patient-focused approach that we take for the patients.

How can risk stratification tools improve the management of intermediate-risk patients with PE?

Classifications are great. There are a couple of classifications that we follow closely, one of them is European Society of Cardiology classification, and the other is from American College of Chest Physicians. The guidelines and the classifications are extremely helpful to do a first step in terms of putting the patient into one of those buckets.

One thing that I think I would like to remind is that, in reality, the patients move between the zones, meaning that patients who are in low-risk may move to the intermediate-risk, patients who are intermediate-risk may move up into high-risk, and it could be vice versa, too; we always hope that patients go in a good direction, but they may go in the wrong direction. Sometimes, using the classification, putting them in a box category, as health care providers, I think we need to be cognizant of the fact that this is a moving target, and we need to adjust as the patient's severity adjusts and presents itself.

Also, 1 of the things that we published recently is that classifications will do a 30-day mortality prediction just based on the blood clot, not just based on the pulmonary embolism, but we are also realizing is that a lot of our patients have a lot of chronic comorbid conditions. If you have a patient with pulmonary embolism and intermediate-risk PE, and if you have a patient with intermediate-risk PE who also has 3 other medical conditions, like COPD [chronic obstructive pulmonary disease], heart failure, that's a different patient group. Unfortunately, the guidelines don't capture that, and they can't because you cannot study that way.

As a clinician, I think we have to be cognizant of the fact, and I think what we learned from our research that we presented at CHEST recently, that patients with multiple comorbidities and PE, their outcomes are much different than the patients who have just the intermediate-risk PE; I think that's something that I want our audience to be cognizant about.

On top of the current classification, we use different biomarkers, which are not in the guidelines, but they're acknowledged in the guidelines. We use lactic acid, we look at the sodium images, hyponatremia, we look at their kidney function, we look at their liver function. Those are simple tests that are available everywhere. I think those are all the markers in organ hypoperfusion, so if you have intermediate-risk PE and you're not sure, you start utilizing additional biomarkers, which are easily available, to kind of categorize your patient who's sick versus who is not.