Multidisciplinary pulmonary embolism care: an exciting time to join the team

Pulmonary embolism (PE) remains a major cause of morbidity and mortality in hospitalized patients and is a top cause of cardiovascular death behind myocardial infarction and stroke, two disease states which have seen the formalization of team-based care that can be rapidly activated and deployed for expeditious and expert treatment. Only recently in this decade, and in conjunction with the advances of new therapeutic options for PE including catheterdirected thrombolysis and thromboaspiration, have we seen the emergence of the PE Response Team (PERT) in an attempt to improve care for this deadly disease. First described by Massachusetts General Hospital and in operation since 2013, the PERT is modeled off of the deployment of Rapid Response Teams meant to bring specialized resources to hospitalized patients in an effort to rescue and prevent further deterioration. The team can be rapidly activated and expert care from multiple stakeholder specialties can be planned and coordinated with the patient and primary physician. Modeled after this team approach, PERTs have rapidly spread in hospitals across America and, in 2015, the PERT Consortium was created to help focus ongoing mission goals, including the creation of registry data on patients treated under this care model. At the time of publication, the PERT Consortium comprises over 60 founding and institutional member hospitals. In this issue of Pulmonary Circulation, Jacob Schultz and colleagues describe the first-year experience of the original eight large tertiary care centers participating in the PERT Registry. In this report, the authors describe characteristics of PERT activations, with a variety in frequency of activations between hospitals and hospital wards. Characteristics of PE are described in terms of presence of right heart strain by biomarker, radiographic or echocardiographic evidence and stratified by risk classification according to European Society of Cardiology guidelines. A variety of treatment options were employed including anticoagulation alone in the majority as well as advanced therapy including systemic or catheter-directed thrombolysis, catheter-directed thromboaspiration, surgical embolectomy, Extracorporeal Membrane Oxygenation, or inferior vena cava filter placement. Finally, event rates for 30-day mortality, major bleeding, and recurrent venous thromboembolism (VTE) are reported and stratified by risk category. This report brings the first multicenter analysis of PERT registry data and highlights some of the phenomena that we in practice in high-volume centers know to be true. However, it leaves some unanswered questions that, hopefully, pooled consortium data will rapidly clarify. The PERT composition is not a one-size-fits-all team and, just as diverse as the patient populations described, must be tailored to a hospital’s capabilities and its population’s needs. Our PERT has isolated physician champions in core subspecialties of Pulmonary/Critical Care Medicine, Pulmonary Hypertension, Advanced Heart Failure Cardiology, Cardiac Surgery, Interventional Cardiology, and Interventional Radiology. Emergency Physicians and Internist experts with an interest in anticoagulation contribute to our team with additional support from Vascular Surgery and Hematology. Notable in this study is a marked difference in location of activation of the teams between hospitals, suggesting the ongoing need for individualized team structure and underscoring the importance in careful scrutiny of quality improvement measures that are integral to each team’s success. The question on every practitioner’s mind at this point is addressed but unfortunately not answered by the limited amount of data presented: outcomes for advanced therapy compared to anticoagulation alone. As reported previously in the initial single-center experience, pooled major bleeding was similar between the groups treated with anticoagulation alone and patients treated with catheter-based techniques, adding important safety data to the evidence base. However, the low event rate in both studies suggests under-powering of the data that will likely require a large registry to answer. This study also points out that in the PERT population, recurrent VTE events occur equally across risk groups, but appeared to trend higher in groups treated with catheter-based strategies and systemic thrombolysis for unclear reasons.