The approach to massive pulmonary embolism

Massive pulmonary embolism (PE) is surprisingly common and is not necessari ly heralded by dramatic symptoms or signs. The death rate from PE remains h igh, and the most common cause of mortality is recurrent PE, not cancer. Pr evention of recurrent embolism with intensive anticoagulation remains the f oundation 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, Howe ver, in patients with massive PE, anticoagulation alone often does not suff ice to prevent death or disability from chronic pulmonary hypertension, Imp ending hemodynamic instability due to massive PE and its attendant ominous prognosis can be detected by rapid identification of moderate or severe rig ht ventricular failure (usually easily with transthoracic echocardiography) , Successful treatment of overt cardiogenic shock, manifested by systemic a rterial hypotension and tachycardia, is far more difficult than implementin g a strategy that champions early intervention after the onset of right ven tricular failure. Among patients with massive PE, thrombolysis and embolect omy (often performed in the interventional angiography laboratory) are bein g used with increasing Skill and improved outcomes. Intensive pharmacologic therapy and mechanical support devices portend a new era of improved inten sive and multidisciplinary management of these gravely ill patients.