Acute pulmonary embolism (PE) encompasses a spectrum of disorders with distinct pathophysiological mechanisms and therapeutic implications. Patients with acute PE who present with normal systemic arterial pressures and no evidence of right ventricular dysfunction have an excellent prognosis when treated with standard anticoagulation alone. Normotensive patients with acute PE and evidence of right ventricular dysfunction are categorized as having submassive PE and comprise a population at increased risk for adverse events and early mortality. Massive PE describes a population of patients with hemodynamic compromise and right ventricular failure who present with syncope, systemic arterial hypotension, cardiogenic shock, or cardiac arrest. Prompt recognition of these PE syndromes, early consideration of primary therapy such as fibrinolysis or embolectomy when appropriate, and timely institution of therapeutic anticoagulation are critical steps in the care of patients with acute PE.

The approach to the adult patient with acute PE will be discussed here with an emphasis on pathophysiological and evidence-based algorithms for the management of acute PE syndromes. The treatment of complicated PE patients, including those with contraindications to fibrinolysis and therapeutic anticoagulation, will be described. In addition, the management of chronic oral anticoagulation for patients with PE and its related pitfalls will be elaborated.

NUMBER OF CREDIT HOURS: The Harvard Medical School designates this educational activity for a maximum of 2 AMA PRA Category 1 credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

COST: $40.00
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OVERALL LEARNING OBJECTIVES:

1. To understand the pathophysiological approach to the management of massive pulmonary embolism (PE)
2. To understand the difference between primary and secondary therapy for massive PE
3. To be able to explain the clinical indications, risks, and benefits of fibrinolysis for massive PE
4. To understand the management of submassive PE in patients with contraindications to fibrinolytic therapy
5. To understand the management of acute PE in patients who have contraindications to therapeutic anticoagulation
6. To be able to describe the options for immediate anticoagulation in patients with acute PE
7. To understand the rationale behind indefinite oral anticoagulation for patients with idiopathic, or unprovoked, venous thromboembolism (VTE)
8. To be able to avoid common pitfalls in the chronic anticoagulation of PE patients

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GREGORY PIAZZA, MD Course Director

Dr. Piazza is a Clinical Instructor in Medicine, Harvard Medical School and, after completing his training in Cardiology at the Beth Israel Deaconess Medical Center, is now a Fellow in Vascular Medicine at the Brigham and Women's Hospital. Dr. Piazza received his medical degree from the University of Massachusetts Medical School in Worcester, Massachusetts and completed his residency in internal medicine at the Beth Israel Deaconess Medical Center in Boston. He served as Chief Medical Resident for the Department of Medicine at Beth Israel Deaconess Medical Center. Dr. Piazza’s research interests include the epidemiology, pathophysiology, diagnosis, treatment, and prevention of venous thromboembolism. In particular, Dr. Piazza has focused on characterizing the demographics, comorbidities and risk factors, clinical presentation, prophylaxis patterns, and treatment of hospitalized medical patients, elderly patients, and heart failure patients with deep vein thrombosis in an effort to improve the utilization of prophylaxis in these vulnerable populations. DISCLOSURE:

SAMUEL Z. GOLDHABER, MD Course Contributor

Samuel Z. Goldhaber, MD, Professor of Medicine at Harvard Medical School, chairs the Venous Disease Coalition. Dr. Goldhaber is a Senior Staff Member of the Cardiovascular Medicine Division of Brigham and Women’s Hospital (BWH). He is Director of the BWH Venous Thromboembolism Research Group and serves as Principal Investigator of a broad range of randomized clinical trials and observational studies related to the prevention, treatment, and epidemiology of venous thromboembolism. Dr. Goldhaber is also Director of the BWH Anticoagulation Service, which cares for more than 2,000 patients. The March 10, 2005, New England Journal of Medicine published his large clinical trial that described a new method using electronic alerts to enhance venous thromboembolism prophylaxis. This intervention reduced symptomatic DVT and PE by 41%, without an increase in bleeding complications. Dr. Goldhaber is also the Principal Investigator of an ongoing multicenter trial on Physician Alerts for patients at high risk of DVT or PE who are not receiving prophylaxis. In May 2006, he co-chaired the 2-day Surgeon General’s Workshop on DVT, which was cosponsored by the National Heart Lung and Blood Institute (NHLBI). He also serves on the National Comprehensive Cancer Network and National Quality Forum to formulate new treatment and prevention guidelines for venous thromboembolism. He is President and one of four Founding Directors of the nonprofit North American Thrombosis Forum (www.NATFonline.org), one of the 19 organizations comprising the Venous Disease Coalition. DISCLOSURE: Company: Sanofi-Aventis; Eisai; Boehringer-Ingelheim; BMS; GSK Type of Relationship: Research Support, Consultant; Research Support, Consultant; Research Support, Consultant; Research Support, Consultant; Research Support

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GRACE HUANG, MD Reviewer

Grace Huang, MD, is the Director of the Office of Educational Technology at the Carl J. Shapiro Institute for Education and Research, a joint venture between HMS and Beth Israel Deaconess Medical Center (BIDMC) in Boston. She also works as a hospitalist at BIDMC. She has spent a number of years designing web-based modules on clinical skills, including computer-based case simulations (“virtual patients”), physical diagnosis tutorials, interactive pathophysiology diagrams, and procedure-based instruction. She serves as a consultant to the Association of American Medical Colleges in their initiative to promote scholarship and sharing of educational materials through MedEdPORTAL. Her clinical research interest is in the impact of a formal hospital-based procedure service on complication rates among internal medicine residents. DISCLOSURE: Dr. Huang's spouse works at Pfizer, Inc., and she holds stock options and shares in the same company.

SYLVIA MCKEAN, MD, FACP Reviewer

Sylvia McKean, MD, FACP is the Medical Director of the BWF Hospitalist Service at Brigham and Women’s Hospital (BWH) in Boston, and the Faulkner Hospital in Jamaica Plain, Massachusetts. Her academic appointment is Associate Professor of Medicine at Harvard Medical School (HMS) and Associate Physician at BWH. Over the past 10 years, Dr. McKean has received more than 15 awards for leadership, excellence and teaching. In 2002, she was appointed “scholar” as a charter member of the HMS Academy in recognition of excellence in medical education and commitment to improvement and innovation in medical education. She received the Society of Hospital Medicine’s 2006 Excellence in Teaching Award in recognition of outstanding teaching in hospital medicine. DISCLOSURE:

WOODY WEISS, MD Reviewer

Dr. Weiss is a graduate of Case Western Reserve Medical School in Cleveland, Ohio. He did his internship and residency at the University of California in San Francisco, California and at Beth Israel Hospital. He had additional pulmonary training in respiratory physiology at Dartmouth Medical School, and he did clinical training in pulmonary diseases at Brigham and Women's Hospital. He is board certified in Internal Medicine, Pulmonary Medicine, and Critical Care Medicine. He has been a member of the pulmonary staff at Beth Israel Hospital and Beth Israel Deaconess Medical Center since 1982. He is now an Associate Professor of Medicine at Harvard Medical School. He has been Director of the Medical Intensive Care Unit at Beth Israel and Beth Israel Deaconess Medical Center since 1982. He has an active research interest in cardiorespiratory control and has several research grants funded by the National Institutes of Health. He has a strong research and clinical interest in cardiorespiratory failure. Dr. Weiss is a member of the American Thoracic Society Section on Critical Care. He has lectured nationally and internationally on a variety of topics related to intensive care medicine. He is currently Chief of the Division of Pulmonary and Critical Care Medicine at Beth Israel Deaconess Medical Center. DISCLOSURE:

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NUMBER OF CREDITS: 2 

Harvard Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Harvard Medical School designates this educational activity for a maximum of 2 AMA PRA Category 1 credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Upon completion of the course you will get a certificate via e-mail within 2 weeks.

Click the image to view a sample of the certificate

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