Shock Syndromes II

The authors reported that Black patients were 13% less likely to receive advanced PE therapy (thrombolysis,

catheter-directed treatment, surgical embolectomy, or extracorporeal membrane oxygenation) than

White patients (OR 0.87; 95% CI, 0.82–0.93; p<0.001), and Asian patients were 24% less likely than

others (OR 0.76; 95% CI, 0.70–0.83; p<0.001). Patients with Medicare insurance were 27% less likely

(OR 0.73; 95% CI, 0.70–0.76; p<0.001), Patients with Medicaid insurance were 32% less likely (OR 0.68;

95% CI, 0.64–0.71; p<0.001), and patients with “other-insurance” (including patients without insurance)

were 14% less likely (OR 0.86; 95% CI 0.81–0.91; p<0.001) to receive advanced therapy than patients

with private insurance.

1.10; 95% CI, 1.03–1.18; p=0.005), and Asian patients had a 50% higher mortality rate than others (OR

1.50; 95% CI, 1.35–1.65; p<0.001). Patients with the lowest income also had a 9% greater mortality rate

(OR 1.09; 95% CI, 1.04–1.14; p=0.001). Among patients with high-risk PE, Black, Hispanic, and Asian

patients had an 11%–50% higher mortality rate than White patients, independent of other factors (p<0.05

for all racial/ethnic groups).

Patient Cases

A 48-year-old woman (weight 75 kg) presents to the ED with shortness of breath. The patient’s hypoxemia

does not improve with supplemental oxygen, and her chest radiograph is not significant for any lung abnor-

malities. A contrasted chest CT scan reveals a PE in the subsegmental branch of the right pulmonary artery

and no RV dilation. The patient’s vital signs and significant laboratory values are as follows: heart rate 118

beats/minute, blood pressure 98/62 mm Hg, urinary output 1 mL/kg/hour, troponin T 0.06 ng/mL, brain

natriuretic peptide 60 pg/mL, lactate 0.9 mmol/L, and SCr 1.1 mg/dL. In addition to initiating a parenteral

anticoagulant, which is best for the patient?

A 56-year-old man (weight 140 kg) with a history of smoking and chronic obstructive pulmonary disease

was admitted to the medical ICU with sudden-onset dyspnea, chest pain, and hypoxemia (Pao2 78%). A

chest CTA reveals a subsegmental PE. His blood pressure is 87/56 mm Hg, now requiring norepinephrine.

Which is the next best step to evaluate and/or treat his PE?