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Semin Thromb Hemost 2016; 42(08): 857-864
DOI: 10.1055/s-0036-1593541
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Pulmonary Embolism Response Teams

Alison S. Witkin
1   Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
2   Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
,
Savanah Harshbarger
2   Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
,
Christopher Kabrhel
2   Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
› Author Affiliations
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Publication History

Publication Date:
21 October 2016 (online)

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Abstract

Pulmonary embolism is a common and often life-threatening event. Treatment options include anticoagulation alone, catheter-directed therapies, and surgical thromboembolectomy. While guidelines exist, there is often controversy over which treatment is most appropriate, particularly for intermediate-risk patients. The traditional care model, in which the primary team is responsible for consulting the appropriate specialists, may be inadequate and inefficient for emergent situations, as ensuring coordination and communication between various consulting services can be a time consuming and confusing process. The Pulmonary Embolism Response Team (PERT) model was developed to improve the quality and efficiency of care for patient with intermediate- and high-risk pulmonary embolism. Activation of the PERT allows for rapid, multidisciplinary discussion among dedicated specialists, which typically includes members of the cardiology, emergency medicine, hematology, pulmonary/critical care, and surgical services. While the majority of patients are still treated with anticoagulation alone, in the event that a more invasive approach is deemed necessary, the team expedites this process. Over the last several years, the PERT model has been adopted at more than 75 health care institutions and may represent a new standard of care.

Keywords

pulmonary embolism - deep vein thrombosis - rapid response team - thrombosis - thrombolysis
 

  • References

  • 1 Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med 2011; 171 (9) 831-837
    CrossrefPubMedSearch in Google Scholar
  • 2 Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data. Arch Intern Med 2003; 163 (14) 1711-1717
    CrossrefPubMedSearch in Google Scholar
  • 3 Jaff MR, McMurtry MS, Archer SL , et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123 (16) 1788-1830
    CrossrefPubMedSearch in Google Scholar
  • 4 Palla A, Rossi G, Falaschi F, Marconi L, Pistolesi M, Prandoni P. Is incidentally detected pulmonary embolism in cancer patients less severe? A case-control study. Cancer Invest 2012; 30 (2) 131-134
    CrossrefPubMedSearch in Google Scholar
  • 5 Becattini C, Agnelli G. Predictors of mortality from pulmonary embolism and their influence on clinical management. Thromb Haemost 2008; 100 (5) 747-751
    PubMedSearch in Google Scholar
  • 6 Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Massive pulmonary embolism. Circulation 2006; 113 (4) 577-582
    CrossrefPubMedSearch in Google Scholar
  • 7 Pollack CV, Schreiber D, Goldhaber SZ , et al. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry). J Am Coll Cardiol 2011; 57 (6) 700-706
    CrossrefPubMedSearch in Google Scholar
  • 8 Becattini C, Agnelli G, Pesavento R , et al. Incidence of chronic thromboembolic pulmonary hypertension after a first episode of pulmonary embolism. Chest 2006; 130 (1) 172-175
    CrossrefPubMedSearch in Google Scholar
  • 9 Pengo V, Lensing AW, Prins MH , et al; Thromboembolic Pulmonary Hypertension Study Group. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004; 350 (22) 2257-2264
    CrossrefPubMedSearch in Google Scholar
  • 10 Martí D, Gómez V, Escobar C , et al. Incidence of symptomatic and asymptomatic chronic thromboembolic pulmonary hypertension [in Spanish]. Arch Bronconeumol 2010; 46 (12) 628-633
    PubMedSearch in Google Scholar
  • 11 van Es J, den Exter PL, Kaptein AA , et al. Quality of life after pulmonary embolism as assessed with SF-36 and PEmb-QoL. Thromb Res 2013; 132 (5) 500-505
    CrossrefPubMedSearch in Google Scholar
  • 12 Kline JA, Steuerwald MT, Marchick MR, Hernandez-Nino J, Rose GA. Prospective evaluation of right ventricular function and functional status 6 months after acute submassive pulmonary embolism: frequency of persistent or subsequent elevation in estimated pulmonary artery pressure. Chest 2009; 136 (5) 1202-1210
    CrossrefPubMedSearch in Google Scholar
  • 13 Klok FA, van Kralingen KW, van Dijk AP , et al. Quality of life in long-term survivors of acute pulmonary embolism. Chest 2010; 138 (6) 1432-1440
    CrossrefPubMedSearch in Google Scholar
  • 14 Klok FA, van der Hulle T, den Exter PL, Lankeit M, Huisman MV, Konstantinides S. The post-PE syndrome: a new concept for chronic complications of pulmonary embolism. Blood Rev 2014; 28 (6) 221-226
    CrossrefPubMedSearch in Google Scholar
  • 15 Kearon C, Akl EA, Ornelas J , et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016; 149 (2) 315-352
    CrossrefPubMedSearch in Google Scholar
  • 16 Guyatt G, Gutterman D, Baumann MH , et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an american college of chest physicians task force. Chest 2006; 129 (1) 174-181
    CrossrefPubMedSearch in Google Scholar
  • 17 Konstantinides SV, Torbicki A, Agnelli G , et al; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35 (43) 3033-3069 , 3069a–3069k
    CrossrefPubMedSearch in Google Scholar
  • 18 Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011; 365 (2) 139-146
    CrossrefPubMedSearch in Google Scholar
  • 19 Provias T, Dudzinski DM, Jaff MR , et al. The Massachusetts General Hospital Pulmonary Embolism Response Team (MGH PERT): creation of a multidisciplinary program to improve care of patients with massive and submassive pulmonary embolism. Hosp Pract (1995) 2014; 42 (1) 31-37
    PubMedSearch in Google Scholar
  • 20 Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. Lancet 1960; 1 (7138) 1309-1312
    PubMedSearch in Google Scholar
  • 21 Kabrhel C, Rosovsky R, Channick R , et al. A Multidisciplinary Pulmonary Embolism Response Team (PERT) -Initial 30-Month Experience with a Novel Approach to Delivery of Care to Patients with Sub-Massive and Massive PE. Chest 2016; 150 (2) 384-393
    CrossrefPubMedSearch in Google Scholar
  • 22 Hull RD, Raskob GE, Brant RF, Pineo GF, Valentine KA. Relation between the time to achieve the lower limit of the APTT therapeutic range and recurrent venous thromboembolism during heparin treatment for deep vein thrombosis. Arch Intern Med 1997; 157 (22) 2562-2568
    CrossrefPubMedSearch in Google Scholar
  • 23 Smith SB, Geske JB, Maguire JM, Zane NA, Carter RE, Morgenthaler TI. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest 2010; 137 (6) 1382-1390
    CrossrefPubMedSearch in Google Scholar
  • 24 Büller HR, Décousus H, Grosso MA , et al; Hokusai-VTE Investigators. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med 2013; 369 (15) 1406-1415
    CrossrefPubMedSearch in Google Scholar
  • 25 Agnelli G, Buller HR, Cohen A , et al; AMPLIFY Investigators. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med 2013; 369 (9) 799-808
    CrossrefPubMedSearch in Google Scholar
  • 26 Schulman S, Kearon C, Kakkar AK , et al; RE-COVER Study Group. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 2009; 361 (24) 2342-2352
    CrossrefPubMedSearch in Google Scholar
  • 27 Büller HR, Prins MH, Lensin AW , et al; EINSTEIN–PE Investigators. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 2012; 366 (14) 1287-1297
    CrossrefPubMedSearch in Google Scholar
  • 28 Goldhaber SZ, Haire WD, Feldstein ML , et al. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion. Lancet 1993; 341 (8844) 507-511
    CrossrefPubMedSearch in Google Scholar
  • 29 Sharma GV, Folland ED, McIntyre KM, Sasahara AA. Long-term benefit of thrombolytic therapy in patients with pulmonary embolism. Vasc Med 2000; 5 (2) 91-95
    CrossrefPubMedSearch in Google Scholar
  • 30 Schwarz F, Stehr H, Zimmermann R, Manthey J, Kübler W. Sustained improvement of pulmonary hemodynamics in patients at rest and during exercise after thrombolytic treatment of massive pulmonary embolism. Circulation 1985; 71 (1) 117-123
    CrossrefPubMedSearch in Google Scholar
  • 31 Daniels LB, Parker JA, Patel SR, Grodstein F, Goldhaber SZ. Relation of duration of symptoms with response to thrombolytic therapy in pulmonary embolism. Am J Cardiol 1997; 80 (2) 184-188
    CrossrefPubMedSearch in Google Scholar
  • 32 Meyer G, Vicaut E, Danays T , et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370 (15) 1402-1411
    CrossrefPubMedSearch in Google Scholar
  • 33 Kline JA, Nordenholz KE, Courtney DM , et al. Treatment of submassive pulmonary embolism with tenecteplase or placebo: cardiopulmonary outcomes at 3 months: multicenter double-blind, placebo-controlled randomized trial. J Thromb Haemost 2014; 12 (4) 459-468
    CrossrefPubMedSearch in Google Scholar
  • 34 Marti C, John G, Konstantinides S , et al. Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2015; 36 (10) 605-614
    CrossrefPubMedSearch in Google Scholar
  • 35 Chatterjee S, Chakraborty A, Weinberg I , et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311 (23) 2414-2421
    CrossrefPubMedSearch in Google Scholar
  • 36 Sharifi M, Bay C, Skrocki L, Rahimi F, Mehdipour M ; “MOPETT” Investigators. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” Trial). Am J Cardiol 2013; 111 (2) 273-277
    CrossrefPubMedSearch in Google Scholar
  • 37 Kucher N, Boekstegers P, Müller OJ , et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation 2014; 129 (4) 479-486
    CrossrefPubMedSearch in Google Scholar
  • 38 Piazza G, Hohlfelder B, Jaff MR , et al; SEATTLE II Investigators. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study. JACC Cardiovasc Interv 2015; 8 (10) 1382-1392
    CrossrefPubMedSearch in Google Scholar
  • 39 Donaldson CW, Baker JN, Narayan RL , et al. Thrombectomy using suction filtration and veno-venous bypass: single center experience with a novel device. Catheter Cardiovasc Interv 2015; 86 (2) E81-E87
    CrossrefPubMedSearch in Google Scholar
  • 40 Dumantepe M, Teymen B, Akturk U, Seren M. Efficacy of rotational thrombectomy on the mortality of patients with massive and submassive pulmonary embolism. J Card Surg 2015; 30 (4) 324-332
    CrossrefPubMedSearch in Google Scholar
  • 41 Samoukovic G, Malas T, deVarennes B. The role of pulmonary embolectomy in the treatment of acute pulmonary embolism: a literature review from 1968 to 2008. Interact Cardiovasc Thorac Surg 2010; 11 (3) 265-270
    CrossrefPubMedSearch in Google Scholar
  • 42 Neely RC, Byrne JG, Gosev I , et al. Surgical embolectomy for acute massive and submassive pulmonary embolism in a series of 115 patients. Ann Thorac Surg 2015; 100 (4) 1245-1251 , discussion 1251–1252
    CrossrefPubMedSearch in Google Scholar
  • 43 Leacche M, Unic D, Goldhaber SZ , et al. Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg 2005; 129 (5) 1018-1023
    CrossrefPubMedSearch in Google Scholar
  • 44 Carroll BJ, Shah RV, Murthy V , et al. Clinical Features and outcomes in adults with cardiogenic shock supported by extracorporeal membrane oxygenation. Am J Cardiol 2015; 116 (10) 1624-1630
    CrossrefPubMedSearch in Google Scholar
  • 45 Decousus H, Leizorovicz A, Parent F , et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med 1998; 338 (7) 409-415
    CrossrefPubMedSearch in Google Scholar
  • 46 Mismetti P, Laporte S, Pellerin O , et al; PREPIC2 Study Group. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. JAMA 2015; 313 (16) 1627-1635
    CrossrefPubMedSearch in Google Scholar