Advertisement

Pulmonary Embolism

  • Dejene Shiferaw
  • Shoaib Faruqi
Chapter

Abstract

The presenting signs and symptoms of pulmonary embolism are non-specific and a high degree of clinical suspicion is needed to make the diagnosis. Presence of a risk factor for VTE should make one think of this diagnosis, in the appropriate setting. Diagnostic algorithms incorporating D-dimer testing have been validated to investigate suspected PE. CT pulmonary angiography (CTPA) is the imaging modality of choice, which should be performed only after appropriate evaluation and risk-stratification. For PE associated with persistent shock, thrombolysis is considered appropriate, whereas anticoagulation is indicated for patients with smaller PE, including sub-massive/intermediate risk PE. A subset of patients with low risk PE, as stratified by scores such as the PESI or sPESI, are appropriate for out-patient care. Those with unprovoked VTE are at increased risk of recurrence. The individual risk of recurrence needs to be considered against the bleeding risk with long term anticoagulation. Direct oral anticoagulants are as effective as warfarin and have a lower risk of bleeding events, and effective reversal agents are becoming available.

References

  1. 1.
    Hull RD, Hirsh J, Carter CJ, Jay RM, Dodd PE, Ockelford PA, et al. Pulmonary angiography, ventilation lung scanning, and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan. Ann Intern Med. 1983;98(6):891–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Kearon C, Ginsberg JS, Hirsh J. The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism. Ann Intern Med. 1998;129(12):1044–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353:1386–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Kasper W, Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol. 1997;30:1165–71.CrossRefPubMedGoogle Scholar
  5. 5.
    Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172(8):1041–6.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Jimenez D, Aujesky D, Moores L, Gómez V, Lobo JL, Uresandi F, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Aujesky D, Roy PM, Verschuren F, Righini M, Osterwalder J, Egloff M, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet. 2011;378(9785):41–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35(43):3033–69. 3069a–3069k.CrossRefPubMedGoogle Scholar
  9. 9.
    Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007;120(10):871–9.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135(2):98–107.CrossRefPubMedGoogle Scholar
  11. 11.
    Carrier M, Righini M, Djurabi RK, Huisman MV, Perrier A, Wells PS, et al. VIDAS D-dimer in combination with clinical pre-test probability to rule out pulmonary embolism. A systematic review of management outcome studies. Thromb Haemost. 2009;101(5):886–92.CrossRefPubMedGoogle Scholar
  12. 12.
    Faruqi S, Kishore N, Bodington R, Meghjee S, Thirumaran M. The diagnostic yield of CTPA: pulmonary embolism, alternative diagnoses and incidental findings. Acute Med. 2016;15(3):130–3.PubMedGoogle Scholar
  13. 13.
    Stein PD, Athanasoulis C, Alavi A, Greenspan RH, Hales CA, Saltzman HA, et al. Complications and validity of pulmonary angiography in acute pulmonary embolism. Circulation. 1992;85(2):462–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Thromboembolic disease in pregnancy and the puerperium: acute management (green-top guideline No. 37b). London: Royal College of Obstetricians and Gynaecologists; 2015. Available at: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37b.pdf.
  15. 15.
    [No authors listed]. The urokinase pulmonary embolism trial: a national cooperative study. Circulation. 1973;47(2 Suppl):II1–108.Google Scholar
  16. 16.
    Marti C, John G, Konstantinides S, Combescure C, Sanchez O, Lankeit M, et al. Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J. 2015;36(10):605–14.CrossRefPubMedGoogle Scholar
  17. 17.
    Jerjes-Sanchez C, Ramírez-Rivera A, de Lourdes García M, Arriaga-Nava R, Valencia S, Rosado-Buzzo A, et al. Streptokinase and heparin versus heparin alone in massive pulmonary embolism: a randomized controlled trial. J Thromb Thrombolysis. 1995;2(3):227–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Meyer G, Vicaut E, Danays T, Agnelli G, Becattini C, Beyer-Westendorf J, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402–11.CrossRefPubMedGoogle Scholar
  19. 19.
    Akl EA, Kahale L, Barba M, Neumann I, Labedi N, Terrenato I, et al. Anticoagulation for the long-term treatment of venous thromboembolism in patients with cancer. Cochrane Database Syst Rev. 2014;7:CD006650.Google Scholar
  20. 20.
    Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med. 1998;338:409–15.CrossRefPubMedGoogle Scholar
  21. 21.
    Piran S, Le Gal G, Wells PS, Gandara E, Righini M, Rodger MA, et al. Outpatient treatment of symptomatic pulmonary embolism: a systematic review and meta-analysis. Thromb Res. 2013;132(5):515–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Respiratory MedicineHull and East Yorkshire Hospitals NHS Trust, Castle Hill HospitalCottinghamUK

Personalised recommendations