As we step into 2024, the field of pulmonary embolism (PE) research stands at a unique
juncture. Traditional interest concerning venous thromboembolism risk factors and
medical therapies is being complemented by unprecedented attention to the potential
impact of novel therapies, the study of pathophysiological interplays between PE and
comorbidities, and research pointing toward the burden of disease beyond the period
of acute care, including health-related quality of life and functional outcomes.
Despite all this progress, in 2023, PE still remains a potentially lethal condition.
New therapeutic interventions have burst onto the scene. However, with every innovation,
new questions arise. How certain are we that they actually work and help patients
live longer, better, or both? How do we integrate these advancements into existing
clinical practice? While anticoagulant and fibrinolysis have been traditional treatments,
a variety of new interventions have emerged, though they often are not incorporated
in main guidelines due to a limited number of robust studies. Dr. Fulton and coauthors
stress the need for a standardized treatment approach, emphasizing the importance
of early risk assessment and multidisciplinary teams such as a Pulmonary Embolism
Response Team, also in light of the growing expertise in mechanical circulatory support
systems and progressively increasing spectrum of treatment modalities.[1] In the same topic, Dr. Bejjani and colleagues discuss right ventricular failure
as a critical issue in PE and as the key tool to refine risk assessment for consideration
of treatments.[2] This review highlights the impact of PE on right ventricular dysfunction, guiding
early risk assessment, acute treatment, and long-term care.
It was our collective endeavor to provide readers with a holistic understanding, combining
traditional clinical guidance with cutting-edge insights on the cross-talks between
PE and other highly prevalent respiratory diseases. Chronic obstructive pulmonary
disease (COPD) is a severe respiratory condition that ranks among the top five global
causes of death, with exacerbations occasionally leading to hospitalizations. Dr.
Bertoletti and colleagues therefore reviewed the interrelationship between COPD and
venous thromboembolism notably PE, highlighting that COPD acts as an important risk
factor for venous thrombosis and can at the same time influence the presentation and
prognosis of patients with acute PE.[3] The review also presents recent findings from major studies illustrating the prevalence
of PE in patients with exacerbated COPD, a condition that may mimic other acute respiratory
conditions, including PE, and reflects on the knowledge gaps. In a similar vein, coronavirus
disease 2019 (COVID-19) triggers a state characterized by lung inflammation favoring
(local) clot formation, which can exacerbate respiratory issues, be easily misdiagnosed,
and ultimately prolong hospitalizations and worsen prognosis. In the review from Dr.
Ortega-Paz and colleagues, the distinctions between COVID-19-related PE and conventional
PE are explored, addressing its origins, significance, and the evolving strategies
for prevention, including insights from antithrombotic therapy studies.[4] To a similar extent, Drs. Pengo and Denas review another immune-mediated condition
that represents an unicum in terms of diagnosis and medical management of patients with venous thromboembolism:
antiphospholipid syndrome.[5] In light of recent evidence from phase 3 trials, they emphasize clinically oriented
aspects covering diagnostic and therapeutic dilemmas. These include the difficulties
in formulating a clear diagnosis, the relative risk of complication across subgroups
of patients with antiphospholipid antibodies, and the recommended treatments. A complex
differential diagnosis with overlap with inflammation and infection also characterizes
septic PE, the clinical entity discussed by Drs. Valerio and Baddour.[6] With clinics and pathophysiology only partially overlapping classic thrombotic PE,
septic PE is progressively gaining clinical relevance because of increasing evidence
on its poor prognosis and the proposition that the rapidly changing epidemiology of
its risk factors—as diverse as injection drug use, cardiac implantable electronic
devices, and thrombophlebitis from soft tissue infections—may lead to an escalation
of cases seen by physicians worldwide over the next years.
Finally, the concept that acute PE can have lasting repercussions well beyond the
initial event may be obvious but has been only recently received extensive attention
for investigation. Many survivors may experience residual symptoms and cardiac impairment
(i.e., post-PE syndrome). Very few of those may ultimately be diagnosed with chronic
thromboembolic pulmonary hypertension, a rare but severe complication arising from
residual (chronic) thrombotic obstructions. These conditions often require medical
surveillance and multidimensional care to address both physical and psychological
sequelae. Dr. Luijten and colleagues highlight that PE survivors can experience a
broad spectrum of symptoms and functional discomforts, even after proper anticoagulation.[7] This review discusses not only the components of post-PE syndrome, but also the
importance of its diagnosis and management, the role of patient-reported outcomes,
and the potential benefits of cardiopulmonary rehabilitation. The impact on patient
quality of life comes as a direct consequence of PE-related complications as well
as comorbidities, which often represent per se a risk factor for the development of
thrombosis. While the link between venous thrombosis and impaired quality of life
has been explored, there is limited research on incorporating quality-of-life assessments
into clinical practice, and the review by Dr. Tavoly and colleagues illustrated potential
approaches based on existing literature.[8]
The past few years have been transformative for PE research. We recognize that we
are in a crucial phase as the disease management undergoes innovative shifts. We hope
the readers will share our excitement for the picked trending topics summarized by
leading experts.
