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PubMedDate not supplied

[Clinical diagnosis of pulmonary embolism].

Pulmonary embolism, a major complication of thromboembolic disease, remains an important cause of mortality, both in surgical and medical practice. In recent literature, one finds two different currents: the first one asserts that pulmonary embolism is overdiagnosed and, therefore, "overtreated" with iatrogenic hemorrhagic complications, when other authors assert that pulmonary embolism is underdiagnosed and "undertreated". It is obvious that clinical diagnosis of non massive, acute pulmonary embolism remains difficult and that the classical triad pleuritic chest pain, hemoptysis and signs of deep venous thrombosis is not frequently found. The clinician should be attentive to the different symptoms and clinical signs which might arouse a suspicion of pulmonary embolism. A large range of investigations is available to confirm the clinical diagnosis. In deep venous thrombosis preceding or accompanying pulmonary embolism, treatment should be instituted at the first signs of venous attack. A precise diagnosis will secondarily be confirmed by phlebography. Any delay in effective early treatment of thromboembolic disease will increase the risk of pulmonary embolism and of the mortality inherent in this dreadful complication.

Diagnosis, Differential↗

PubMed2002

Is thrombolytic therapy effective for pulmonary embolism?

Pulmonary embolism is a disorder that is associated with significant morbidity and mortality. Right-sided heart failure and recurrent pulmonary embolism are the main causes of death associated with pulmonary embolism in the first two weeks after the embolic event. Thrombolysis is a potentially lifesaving therapy when used in conjunction with standard anticoagulation. However, it has significant side effects and must therefore be used with caution. Indications for thrombolysis are not well defined and are thus controversial. The only current absolute indication is massive pulmonary embolism with hypotension. Other potential indications include right heart dysfunction, recurrent pulmonary embolism and the prevention of pulmonary hypertension. However, no evidence exists to show benefit of thrombolytic therapy over standard anticoagulation therapy for recurrent pulmonary embolism, mortality or chronic complications. Bleeding is the most common complication of thrombolysis and may be fatal.

Anticoagulants↗

PubMed1965

PREVENTING, RECOGNIZING, TREATING PULMONARY EMBOLISM.

PULMONARY EMBOLISM OCCURS IN THREE FORMS: (1) Asymptomatic "silent" embolization of lungs; (2) pulmonary infarction; and (3) massive pulmonary embolization leading to acute cor pulmonale. The commonest source of emboli are veins of the lower extremities and of the pelvic organs. The prevention and the treatment of pulmonary embolism overlap, for except for the heroic procedure of pulmonary embolectomy, treatment is equivalent to the prevention of further emboli. The diagnosis may be easy in typical cases and very difficult in others.

Acute Disease↗

PubMedDate not supplied

Pulmonary embolism.

Pulmonary embolism is a common medical problem whose incidence is likely to increase in our aging population. Although it is life-threatening, effective therapy exists. The treatment is not, however, without significant complications. Thus, accurate diagnosis is important. Unfortunately, the clinical manifestations of pulmonary embolism are nonspecific. Furthermore, in many patients the symptoms of an acute embolism are superimposed on underlying chronic heart or lung disease. Thus, a high index of suspicion is needed to identify pulmonary emboli. Laboratory parameters, including arterial oxygen tensions and electrocardiography, are as nonspecific as the clinical signs. They may be more useful in excluding another process than in diagnosing pulmonary embolism. The first radiologic examination is the chest radiograph, but the clinical symptoms are frequently out of proportion to the findings on the chest films. Classic manifestations of pulmonary embolism on the chest radiograph include a wedge-shaped peripheral opacity and a segmental or lobar diminution in vascularity with prominent central arteries. However, these findings are not commonly seen and, even when present, are not specific. Even less specific findings include cardiomegaly, pulmonary infiltrate, elevation of a hemidiaphragm, and pleural effusion. Many patients with pulmonary embolism may have a normal chest radiograph. The chest radiograph is essential, however, for two purposes. First, it may identify another cause of the patient's symptoms, such as a rib fracture, dissecting aortic aneurysm, or pneumothorax. Second, a chest radiograph is essential to interpretation of the radionuclide V/Q scan. The perfusion scan accurately reflects the perfusion of the lung. However, a perfusion defect may result from a variety of etiologies. Any process such as vascular stenosis or compression by tumor may restrict blood flow. In addition, areas of the lung that are not well ventilated will be poorly perfused. Thus, a ventilation scan and a chest radiograph are essential to optimal interpretation of the perfusion scan. Ventilation/perfusion scans are interpreted as degrees of probability of pulmonary embolism. Emboli are not present in patients with a normal V/Q scan. An embolus is unlikely (10%-15%) among patients with a low-probability V/Q scan. However, small emboli that are nonocclusive may be present, and pulmonary arteriography may be used to further evaluate patients with a high clinical suspicion of pulmonary embolus.(ABSTRACT TRUNCATED AT 400 WORDS)

Angiography↗

PubMed2000

The place of helical CT scanning in acute pulmonary embolism.

Pulmonary embolism is a relative common, potentially fatal disorder that clinicians have difficulty detecting and difficulty diagnosing. Deep venous thrombosis (DVT) is the most important source of thrombi. Early and accurate diagnosis is essential for efficient therapy. Therapy is based on long-term anticoagulation and has an important impact on the mortality and morbidity of pulmonary embolism. For the diagnosis of pulmonary embolism, the ventilation/perfusion (V/Q) scan is still the first examination in many instances. A normal V/Q scan or the combination of a low probability scan and a low clinical suspicion are associated with a prevalence of pulmonary embolism of 4%. The combination of a high-probability V/Q scan and a strong clinical suspicion has a prevalence of pulmonary embolism of 96%. All other results should be considered as non-diagnostic. However, the number of non-diagnostic V/Q examinations can be as high as 70%. Nevertheless, an additional pulmonary angiography will be performed in only in 15% of these cases. In the low pre-test probability group (poor clinical suspicion, absence of risk factors and no medical history) the V/Q scan is useful as a screening test ("rule-out" strategy). When the pre-test probability is higher or in other cases in which early diagnosis is necessary ("rule-in" strategy), a contrast-enhanced spiral CT of the pulmonary arteries (possibly in combination with ultrasonography of the lower limbs) is the most accurate examination.

Acute Disease↗

PubMed1983

Enlargement of the right descending pulmonary artery in pulmonary embolism.

Pulmonary embolism often is undetected during life, even though adequate diagnostic procedures are available, probably because the condition is not suspected. Chest radiographs were reviewed for changes in the right descending pulmonary artery in 73 patients with confirmed pulmonary embolism and in 85 in whom the original suspicion subsequently was not confirmed. In embolic patients, the vessel, measured at four different levels starting from the superior venous angle, was larger during acute embolization than some weeks later. In particular, the two proximal diameters of descending pulmonary artery were significantly enlarged (p less than 0.01). This enlargement of the superior part was responsible for the shape modification of the vessel, which appeared to taper off sharply. Some weeks later, the artery took back its regular cone shape, tapering gently. In about one-fourth of the patients with pulmonary embolism, enlargement and shape modification were so marked that the artery showed a special "sausage" appearance. This feature did not occur in patients with unconfirmed suspicion of pulmonary embolism. Recognition of enlargement of the descending pulmonary artery may increase suspicion of pulmonary embolism; in particular, detection of "sausage" appearance of the vessel should identify patients with high probability of disease.

Adult↗

PubMed1994

[Long term observations of patients after percutaneous inferior vena cava filter placement for recurrent pulmonary embolism].

Pulmonary embolism remains an important cause of mortality despite recent advances in medical therapy. The inferior vena cava filter has been devised for treatment of pulmonary embolism. The Gunter inferior vena cava filter was inserted percutaneously in 6 patients with recurrent pulmonary embolism despite anticoagulation therapy. No complications were observed during this procedure. Two patients died after filter placement (one after six weeks one after 1.5 year) because of right heart failure observed before procedure. The other four patients showed no signs of pulmonary embolism during four years follow-up. We conclude that percutaneous insertion of the Gunter filter is a safe and effective technique for prevention of recurrent pulmonary embolism.

Adult↗

PubMed1989

Pathogenesis and management of acute pulmonary embolism.

Pulmonary embolism can produce severe cardiopulmonary dysfunction characterized by pulmonary artery hypertension, right ventricular failure, and hypoxemia. The search for the source of a pulmonary embolus, by exploration of the veins of the lower limbs and the inferior vena cava should be systematically carried out in all cases of pulmonary embolus which are not immediately life-threatening to the patient. The treatment of deep vein thrombosis associated with pulmonary embolism with thrombolytic agents has been proposed and utilized for approximately 20 years. Although superior results have been claimed with thrombolytic agents, the use of this type of treatment remains limited to massive or sub-massive pulmonary embolism. Fibrinolytic agents with high specificity for fibrin in the thrombi and little systemic activation of the fibrinolytic system have been developed and tested in preliminary clinical trials of patients with acute pulmonary embolism. The largest published experience available has been with recombinant tissue plasminogen activator (rtPA). The acylated streptokinase-plasminogen complex (APSAC) and pro-urokinase also gave promising results. All these agents were accompanied by unexpectedly high incidence of systemic activation of the fibrinolytic system and by hemorrhagic complications with frequencies similar to those that follows the use of first generation products (urokinase and streptokinase). Hence, their superior clinical efficacy must be clearly proven before they are substituted for a more widely available and less expensive drug, such as streptokinase.

Acute Disease↗

PubMed1996

Clinical diagnosis and management of the patient with deep venous thromboembolism and acute pulmonary embolism.

Pulmonary embolism is the third most common acute cause of death in the United States. There are approximately 500,000 cases annually in this country, leading to death in 50,000. Subjective symptoms and objective findings can oftentimes be confusing and nonspecific. A pulmonary embolism is defined as an occlusion of one or more pulmonary vessels by material that has traveled there from outside of the lung and is usually caused by a dislodged thrombus that originated in the deep veins of the legs or pelvis. Risk factors include older age, prior thromboembolism, immobility, cancer, chronic disease, congestive heart failure, pelvic and lower extremity surgery, varicosities, obesity, and oral contraception. This article will discuss current modalities that are used in the evaluation of deep venous thromboembolism and pulmonary embolism and include ventilation/perfusion scan, ultrasonography, impedance plethysmography, pulmonary angiography, and newer tests including D-dimer assays and spiral computed tomography. Medical management including simple and complex decision making, anticoagulation, and thrombolytic therapy will also be discussed. An ounce of prevention is worth a pound of gold--identification of risk factors and the use of appropriate therapeutic measures can reduce an individual's risk for deep venous thromboembolism and pulmonary embolism.

Anticoagulants↗

PubMed2000

[Clinical characteristics of pulmonary embolism].

Pulmonary embolism is nearly always a complication of deep venous thrombosis. The evaluation of risk factors for venous thromboembolism not only aids diagnosis but also guides decisions about the intensity of prophylactic measures. As both the extent and chronicity of pulmonary vascular obstruction vary widely, pulmonary embolism can produce widely differing clinical pictures. From the clinical, pathophysiological and therapeutical point of view, it is convenient to classify pulmonary embolism into four types: acute minor embolism (dyspnoea with or without pleuritic pain or haemoptysis), acute massive embolism (hemodynamic instability), subacute massive embolism (mimicking heart failure or indolent pneumonia), and chronic thromboembolic pulmonary hypertension (slowly progressing dyspnoea). This classification is of importance not only for the rational diagnosis and differential diagnosis, but also for the institution of adequate therapy. Because the disease has many nonspecific manifestations but no pathognomonic symptoms or signs, it is impossible to prove the diagnosis of pulmonary embolism alone on the basis of clinical presentation.

Humans↗

PubMed2004

Epidemiology, diagnosis, and therapy of pulmonary embolism.

Pulmonary embolism is a frequently observed clinical symptom. Its mortality rate is ca. 10 % und occurs mainly in the acute phasis. Immobilization, surgery, old age, malignancies, hormonal factors as well as inherited or acquired thrombophilia are important risk factors. Spiral computed tomography and ventilation-perfusion-scintigraphy are the decisive imaging methods. Pulmonary angiography is still the gold standard. The risk of pulmonary embolism could be lowered by 50 % through prophylaxis with unfractioned or low-molecular-weight heparin. The therapy of pulmonary embolism stratifies the clinical grade and reaches from ambulant therapy with low-molecular-weight heparin to thrombolysis or embolectomy in massive pulmonary embolism. Long-term anticoagulation, usually with vitamin-K-antagonists, should be applied according to the individual risk profile of the patient.

Angiography↗

PubMed1999

Heparin and low molecular weight heparin for treatment of acute pulmonary embolism.

Pulmonary embolism occurs in more than 175,000 patients each year in the United States. The objectives of treatment are to prevent death from the existing embolus, to prevent death and morbidity from recurrent pulmonary embolism, and to prevent morbidity from recurrent deep-vein thrombosis. For patients with adequate cardiorespiratory reserve, the primary objective is to prevent recurrent pulmonary embolism. Anticoagulant therapy with intravenous unfractionated heparin or subcutaneous low molecular weight heparin followed by oral anticoagulant treatment for at least 3 months is the treatment of choice for most of these patients. Clinical trials indicate that the effectiveness of intravenous heparin depends on achieving an adequate heparin effect (activated partial thromboplastin time above lower limit) during the initial 24 hours. A validated protocol for intravenous heparin should be used to lessen the likelihood of delayed heparinization. Low molecular weight heparin given subcutaneously either once or twice daily is as effective as intravenous heparin for the treatment of patients with deep-vein thrombosis and submassive pulmonary embolism. Low molecular weight heparin enables many patients with uncomplicated deep-vein thrombosis to be treated in an outpatient setting.

Acute Disease↗

PubMed1993

[Clinical aspects, diagnosis and therapy of pulmonary embolism].

Pulmonary embolism is a frequent and malignant complication of other diseases. To consider this is the most important step. ECG, pO2/pCO2, chest X-ray are used for differential diagnosis; pulmonary embolism is directly confirmed by scintigraphy, echocardiography, pulmonary angiography and pulmonary artery catheterisation, supplemented by examination of lower venous system (sonography, phlebography). Small emboli should also be noted as a signal of dangerous recurrence. The choice of the therapeutic method (embolectomy, fibrinolysis, anticoagulation) depends on the severity of pulmonary embolism, available methods and present contraindications. Depending upon the severity and general condition of the patient, it may be necessary to disregard possible contraindications against therapeutic methods that may cause desobliteration. Anticoagulation is used as prophylactic method, in exceptional cases a blockade is applied to the vena cava inferior.

Diagnostic Imaging↗

PubMed1985

Unusual pulmonary angiographic findings in suspected pulmonary embolism.

Pulmonary arteriography is most commonly performed to diagnose pulmonary embolism. A variety of clinical entities, however, may mimic pulmonary embolism both clinically and scintigraphically. Five patients with abnormal pulmonary arteriograms resulting from diseases other than pulmonary embolism are presented. The clinical, radiographic, and pathologic findings and long-term follow-up in these patients are described. Awareness of the angiographic patterns seen in these unusual cases is important in the differential diagnosis of pulmonary thromboembolism.

Adolescent↗

PubMed1997

Utilization of electron beam CT scan in diagnosis of pulmonary embolism.

Pulmonary embolism is a difficult entity to diagnose clinically and pulmonary angiogram has been the gold standard for the diagnosis. Our objective was to evaluate the usefulness of electron beam (Ultrafast) CT scan in aiding the diagnosis of such an entity, thus avoiding an invasive procedure. Between April 1995 and March 1996 we prospectively studied 20 patients with clinical suspicion of pulmonary embolism by conventional perfusion scan of the lung, by invasive pulmonary angiography and by contrast enhanced electron beam CT scan. Simple statistic correlation between the 3 methods was obtained in regard to sensitivity and specificity utilizing the pulmonary angiogram as the gold standard. The sensitivity and specificity of contrast enhanced electron beam CT scanning was 95 per cent and 100 per cent respectively. The correlation of positive and negative result of all three imaging modalities was 60 per cent. Contrast enhanced electron beam (Ultrafast) CT scan is a good alternative diagnostic modality for pulmonary embolism.

Adult↗

PubMed1990

Echocardiographic diagnosis and surgical treatment of postpartum pulmonary embolism.

Pulmonary embolism remains a problem in the United States in terms of both morbidity and mortality. New diagnostic modalities to make rapid diagnosis are now available, and allow for bedside diagnosis of pulmonary embolism without the use of pulmonary angiography. As a reference, a case involving a postpartum patient is reviewed. Use of echocardiography, a device readily available even in small institutions, allowed for early diagnosis and institution of therapy in this particular case and in others. Diagnostic features of pulmonary embolism are discussed and the literature is reviewed.

Abdomen↗

PubMed1988

Scintigraphic control of pulmonary embolism.

Pulmonary embolism was diagnosed by combined perfusion and ventilation scintigraphy in 30 patients. A control examination 6 months later revealed pulmonary embolism or infarction in 8, in spite of conventional treatment. Therefore, patients treated for pulmonary embolism should be reexamined 3 to 6 months after diagnosis.

Adult↗

PubMed1985

Evaluation of pulmonary embolism.

Pulmonary embolism is a common disease entity that is difficult to diagnose accurately by noninvasive methods. Ventilation-perfusion is a pivotal study in the evaluation of patients with suspected pulmonary embolism. The role of standard and newer modalities in evaluating pulmonary embolism is discussed in this article.

Angiography↗