ABSTRACT
Massive pulmonary embolism (PE) is surprisingly common and is not necessarily heralded
by dramatic symptoms or signs. The death rate from PE remains high, and the most common
cause of mortality is recurrent PE, not cancer. Prevention of recurrent embolism with
intensive anticoagulation remains the foundation of therapy. The Food and Drug Administration
has approved use of the low molecular weight heparin enoxaparin for inpatient treatment
of deep venous thrombosis (DVT) with or without PE as a ``bridge'' to warfarin. However,
in patients with massive PE, anticoagulation alone often does not suffice to prevent
death or disability from chronic pulmonary hypertension. Impending hemodynamic instability
due to massive PE and its attendant ominous prognosis can be detected by rapid identification
of moderate or severe right ventricular failure (usually easily with transthoracic
echocardiography). Successful treatment of overt cardiogenic shock, manifested by
systemic arterial hypotension and tachycardia, is far more difficult than implementing
a strategy that champions early intervention after the onset of right ventricular
failure. Among patients with massive PE, thrombolysis and embolectomy (often performed
in the interventional angiography laboratory) are being used with increasing skill
and improved outcomes. Intensive pharmacologic therapy and mechanical support devices
portend a new era of improved intensive and multidisciplinary management of these
gravely ill patients.
KEYWORD
Pulmonary embolism - thrombolysis - embolectomy - heparin - low molecular weight heparin
