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PubMedDate not supplied

New therapeutic approaches in pulmonary embolism.

Pulmonary embolism as a part of venous thromboembolic disease has a broad spectrum of clinical presentations from minimal disease to life-threatening right heart failure. Therapy has to be guided by the risk associated with the individual clinical state of the patient. As long as hemodynamics are entirely stable, anticoagulation is given in order to prevent early or late recurrence, thereby allowing for endogeneous thrombolysis and recovery. In hemodynamically instable patients, i.e. patients under cardiopulmonary resuscitation or in shock, there is the need for a rapid reduction of thrombus mass in order to restore right ventricular function. Systemic thrombolysis is the most feasible modality to reduce the thrombus burden of the pulmonary circulation in the short term. For hemodynamically stable patients with right ventricular dysfunction as assessed by echocardiography, there is still some controversy as to whether thrombolysis improves the long-term outcome. At the least, thrombolysis may positively modify the short-term course of acute disease in patients with an extremely low risk of bleeding. When the acute phase has been overcome, secondary prophylaxis with vitamin K antagonists has to be given. The duration of secondary prophylaxis requires an individual assessment of both the risk of recurrence and the risk of bleeding. In the near future, new anticoagulant drugs such as direct thrombin and factor Xa inhibitors will offer new treatment modalities for the acute phase as well as for secondary prophylaxis.

Anticoagulants↗

PubMed1992

[Current etiopathogenic guides in pulmonary embolism].

Pulmonary embolism is still a dangerous postoperative complication in spite of antithrombotic prophylaxis. The paper examines the etiopathogenetic stages of the disease and stresses the relevance of Wircov's triad today, even in the light of recent acquisitions which highlight the role of endothelium as a modulator of the fibrinolytic process.

Adenocarcinoma↗

PubMed2004

Update on pulmonary embolism.

Pulmonary embolism is a medical condition frequently overlooked in patients who present clinical symptoms that may suggest other more common cardiovascular conditions. As a result, missing such a diagnosis may unfortunately cost many lives. In this article the pathogenesis, etiologies and clinical features of this illness is reviewed. The diagnostic tools as well as the medical treatment available at hand today in the management of this condition is also discussed.

Anticoagulants↗

PubMed2005

Likelihood ratios increase diagnostic certainty in pulmonary embolism.

Pulmonary embolism (PE) is a difficult diagnosis to confirm. The choice of tests has led to a myriad of algorithms. Diagnostic uncertainty can be quantified by the application of the tests' likelihood ratios (LR). Positive and negative LR enable the conversion of a pretest to a post-test probability, given a positive and negative test result, respectively. Thus, a pretest probability of <17% and a negative D-dimer with a negative LR of 0.05 (sensitivity 98%, specificity 40%) lead to a post-test probability of PE of <1%. Ventilation perfusion (V/Q) scans with a normal, very low, low, intermediate and high probability result have an LR of 0, 0.125, 0.25, 1 and 17, respectively. Also, patients with a V/Q scan result other than normal or high probability still have a post-test probability of PE from 3 to 65%. Positive and negative computed tomography pulmonary angiograms (CTPA) have an LR of 8.6 and 0.06, respectively (sensitivity 95%, specificity 89%). Patients with a high pretest probability and negative CTPA again still have a post-test probability of more than 10%. However, as the post-test probability after one test becomes the pretest probability for the next, test results used cumulatively progressively narrow the gap to a final diagnosis. The post-test probability after a D-dimer, V/Q scan, CTPA, leg ultrasound or pulmonary angiography, alone or in any combination or in any order, can be calculated using their LR. Use of LR thus assists in the precise interpretation of test results, such as in complex algorithms for PE.

Angiography↗

PubMedDate not supplied

[Diagnosis and treatment of pulmonary embolism].

Pulmonary embolism (PE) is a common disease that poses a major diagnostic challenge because symptoms and signs are neither sensitive nor specific. However, patients with suspected PE can be classified into low, moderate and high clinical probability groups on the basis of symptoms and signs of PE, the presence of risk factors and the presence or absence of a likely alternative diagnosis. Stratification of patients into groups according to the clinical or pretest probability is imperative for proper selection of further diagnostic tests. The role of D-dimer testing is limited to the ruling out of PE in patients with low or moderate clinical probability. Conversely D-dimer testing is useless in patients, with high clinical probability. Chest CT has become an attractive means for an accurate diagnosis of PE and may replace lung scanning as first-line imaging test in particular in patients with underlying pulmonary disease or abnormal chest radiograph. Initial treatment for patients with non massive PE consists of therapeutic anti-coagulation with low molecular weight heparin (LMWH) and early overlapping with oral anticoagulants. In patients with active cancer, long-term treatment with LMWH is recommended. Duration of anticoagulant treatment is based on the balance between the risk of recurrent venous thromboembolism (depending mainly on the reversibility of risk factor, the presence of cancer, thrombophilia or previous venous thromboembolic episodes) and the risk of bleeding.

Anticoagulants↗

PubMed2001

Looking for deep vein thrombosis in suspected pulmonary embolism.

Pulmonary embolism (PE) and deep vein thrombosis are two facets of the same disease, that is, venous thromboembolism (VTE). In patients with angiographically proven PE, the prevalence of proximal deep vein thrombosis by venography is around 70%. The sensitivity of compression ultrasonography (US) for the diagnosis of acute VTE in patients with a suspicion of PE is between 40 and 60%, with a high specificity (96 to 100%). Taking into account the 20 to 30% prevalence of PE in a population consulting for suspicion of this disease, the first line use of compression US will allow the diagnosis of acute VTE in half of patients with confirmed PE, that is, in 10 to 15% of patients addressed for suspicion of PE. In outpatients, the first line use of D-dimers which will exclude acute VTE in one-third of the initial population will slightly increase the reliability of compression US as a first imaging test. New tools of looking for deep vein thrombosis, such as computed tomographic venography coupled with computed tomographic pulmonary angiography, could become an interesting approach in the diagnostic strategy of PE, but require adequate evaluation in prospective studies.

Biomarkers↗

PubMed1997

New imaging techniques for the diagnosis of pulmonary embolism.

Pulmonary embolism (PE) remains a common cause of illness and death. Appropriate therapy requires timely diagnosis, but the currently available noninvasive diagnostic methods lack adequate sensitivity and specificity. In particular the vast majority of ventilation-perfusion scans are unable to confirm or reliably exclude PE, cannot differentiate between acute and chronic PE, and provide no clues about possible alternate explanations of presenting symptoms (even if PE can be excluded). Although the precise role of these scans in the diagnosis of PE remains to be clarified, recent advances appear to ensure a place for magnetic resonance imaging and helical computed tomography in the diagnostic evaluation of PE in the near future.

Angiography, Digital Subtraction↗

PubMed2001

The relationship between FV Leiden and pulmonary embolism.

Pulmonary embolism (PE) is one of the leading causes of in-patient hospital deaths. As a consequence, the identification of hemostatic variables that could identify those at risk would be important in reducing mortality. It has previously been thought that deep vein thrombosis and PE are a single disease entity and would, therefore, have the same risk factors. This view is changing, however, with the realization that the prevalence of FV Leiden, a recognized genetic risk factor for deep vein thrombosis, may be a 'milder' genetic risk factor for PE. These observations suggest that PE is not only associated with a different set of risk factors, but may be reflective of a different clot structure.

Factor V↗

PubMed2005

Small left atrium: an adjunctive sign of hemodynamically compromised massive pulmonary embolism.

Pulmonary embolism (PE) is a common disease with a high mortality rate due to right ventricular dysfunction and underfilling of the left ventricle. We present a case of a 33-year-old man with hemodynamically compromised massive PE. His left atrium was collapsed with marked dilatation of the right atrium and ventricle on multi-detector-row CT scans. The patient was treated with an intracatheter injection of a mutant tissue-type plasminogen activator and subsequently showed clinical and radiological improvements. The small left atrial size in combination with a right ventricular pressure overload was considered to be an adjunctive sign of hemodynamically compromised massive PE.

Adult↗

PubMed1984

The use of 99Tcm-DTPA aerosol ventilation scintigraphy in the diagnosis of pulmonary embolism.

Pulmonary scintigraphy is now established as a sensitive and noninvasive method for diagnosing pulmonary embolism (PE). The diagnostic specificity is increased if the perfusion study is combined with assessment of regional ventilation. The latter is usually performed using radioactive gases, either 133Xe or 81Krm, but these have some disadvantages. We report here a method for ventilation scintigraphy using 99Tcm-DTPA aerosol, previously described for the measurement of lung permeability, and present our findings in 20 patients. The system is easy to use and six-view images obtained can be readily compared with perfusion images. No data processing is required and any hospital with gamma camera facilities can use the system. Thus patients with suspected PE can have combined V/Q scintigrams to establish the diagnosis of PE and unnecessary treatment can be avoided.

Aerosols↗

PubMed1987

Scintigraphic evaluation of pulmonary embolism.

Pulmonary embolism (PE) is difficult to diagnose. The clinical signs and symptoms of the disorder are nonspecific, and the results of laboratory tests are undependable. Accordingly, imaging studies have played a major role in evaluation of patients with suspected PE. Chest radiography is an essential part of this imaging evaluation, but is neither sensitive nor specific, per se. The radiograph is used primarily to provide a regional comparison for ventilation-perfusion (V-P) scintigraphy. V-P scintigraphy typically is the pivotal noninvasive approach to diagnosis of PE. Multi-view perfusion scintigraphy is a sensitive means for detecting the multiple, wedge-shaped defects characteristic of PE. The perfusion scan's inherent nonspecificity is improved by the ventilation study, which reveals abnormalities of ventilation that account for perfusion defects not caused by PE. Multi-view ventilation imaging with either the xenon gases, Kr-81m or radioaerosols is useful for comparison with perfusion scans. When performed properly and interpreted within the guidelines of current diagnostic schemes for scintigraphy, V-P studies provide approximately 90% reliability for the diagnosis of PE. When used alone or in conjunction with noninvasive studies of deep venous thrombosis, they provide an excellent basis for selection of certain patients for pulmonary angiography, and for other decisions about the clinical management of patients with suspected PE.

Humans↗

PubMed2005

Update on the diagnosis and management of pulmonary embolism.

Pulmonary embolism (PE) is a common and often fatal disease. In the US, an estimated 40-53 people per 100,000 are diagnosed with PE annually and approximately 60,000 die from the disease. Diagnosis is difficult because symptoms are non-specific; however, a quick and accurate diagnosis is critical because, with appropriate therapy, the risk of recurrent (and potentially fatal) PE can be greatly reduced. Recent publication of prediction rules and improved non-invasive diagnostic tools have simplified diagnostic algorithms for PE. The efficacy of the standard treatment for PE, initial administration of continuous i.v. unfractionated heparin overlapped with long-term oral anticoagulation, is well established. However, newer treatment options such as low-molecular-weight heparins and the pentasaccharides may offer similar efficacy with improved convenience.

Algorithms↗

PubMed2003

MRI for the diagnosis of pulmonary embolism.

Pulmonary embolism (PE) is one of the most frequently encountered clinical emergencies. The diagnosis often involves multiple diagnostic tests, which need to be carried out rapidly to assist in the safe management of the patient. Recent strides in computed tomography (CT) have made big improvements in patient management and efficiency of diagnostic imaging. This review article describes the developments in magnetic resonance (MR) techniques for the diagnosis of acute PE. Techniques include MR angiography (MRA) and thrombus imaging for direct clot visualization, perfusion MR, and combined perfusion-ventilation MR. As will be demonstrated, some of these techniques are now entering the clinical arena, and it is anticipated that MR imaging (MRI) will have an increasing role in the initial diagnosis and follow-up of patients with acute PE.

Acute Disease↗

PubMed2006

[Diagnosis and therapy of pulmonary embolism].

Pulmonary embolism (PE) as a potentially life-threatening condition requires immediate medical intervention. Even the mere suspicion of a PE demands the initiation of a therapy with heparin. According to the patient's hemodynamic stability further diagnostic and therapeutic steps have to be taken. In case of a stable hemodynamic situation both the clinical probability of a PE and diagnostic imaging as well as the determination of D-dimers lead to the diagnosis. These patients should be anticoagulated with heparin. Unstable hemodynamic patients need to be monitored on the intensive care unit; echocardiography and, if needed, spiral computed tomography are the most important diagnostic tools. Due to this serious situation lung artery perfusion needs to be restituted by thrombolysis. Additionally, secondary prevention with vitamin K antagonists (INR [International Normalized Ratio] 2.0-3.0) is recommended depending on anamnesis and accordance to a risk group.

Angiography↗

PubMed2004

Pulmonary embolism.

Pulmonary embolism (PE) is a common illness that can cause death and disability. It is difficult to detect because patients present with a wide array of symptoms and signs. The clinical setting can raise suspicion, and certain inherited and acquired risk factors predispose susceptible individuals. D-dimer concentration in blood is the best laboratory screening test, and chest CT has become the most widespread imaging test. Treatment requires rapid and accurate risk stratification before haemodynamic decompensation and the development of cardiogenic shock. Anticoagulation is the foundation of therapy. Right-ventricular dysfunction on echocardiography and higher than normal concentrations of troponin identify high-risk patients who might need escalation of therapy with thrombolysis or embolectomy even if the blood pressure is normal on presentation. When patients are admitted to medical wards or when patients undergo surgery, their physicians should prescribe prophylactic measures to prevent PE. After hospital discharge, prophylaxis should continue for about a month for patients at high risk of thromboembolism.

Humans↗

PubMed1995

The role of suspicion in the diagnosis of pulmonary embolism.

Pulmonary embolism (PE) is largely undiagnosed because clinical suspicion is not raised in most instances, and thus, patients with PE go undetected. In this paper, we try to define the role of clinical assessment (including chest radiography, electrocardiogram, arterial blood gas analysis) in making the diagnosis early, accurate, and at low cost, and propose a flow chart to be used in clinical practice. All patients with otherwise unexplained dyspnea or chest pain should be sent for perfusion lung scintigraphy; accordingly, underdetection of PE and mortality of PE should be reduced. If, within 1 h after the clinical suspicion has been raised, the above-mentioned simple and noninvasive examinations are available, they may be employed to reduce the number of unnecessary procedures, without losing patients actually affected by PE. Finally, when diagnostic tools are not promptly available, noninvasive techniques may be employed to identify patients with the highest probability of PE where to start with heparin coverage while waiting for definitive diagnosis.

Clinical Protocols↗

PubMed2004

[Temporary vena cava filters for prevention of pulmonary embolism].

Pulmonary embolism (PE) is a serious complication in deep venous thrombosis (DVT), and the prevention of PE is a major target of treatment. Vena cava filters (VCF) can be inserted, and the temporary type and retrievable type of VCF have appeared in recent years in addition to permanent models. These have introduced new criteria for VCF insertion and changes in the algorithm for the treatment of PE. Among cases traditionally calling for permanent VCF, those requiring prevention of PE, especially in the early stage, are suitable for temporary VCF insertion. These include floating thrombi in the acute DVT phase, the perioperative period of thrombectomy or endovascular treatment for DVT, surgery for an abdominal mass compressing the vena cava or iliac veins, and secondary prophylaxis in the early stage of PE. High-risk patients such as parturient cases with DVT and those with multiple traumatic injuries should also be considered. However, there is little evidence concerning temporary VCF, and further investigations are necessary on insertion methods and indications.

Humans↗

PubMed2004

Pulmonary embolism.

Pulmonary embolism (PE) is an important health problem and often a major clinical challenge, not only because of the low specificity of its clinical manifestations but also because of the increasing number of medical circumstances that are risk factors for this illness and the importance of early identification, since prompt and appropriate treatment can decrease mortality from this disease by about 25%. In recent years research on PE has been extensive, directed mainly at trying to determine and characterize its risk factors, establish new clinical probability algorithms, develop new diagnostic methods and put existing ones into perspective, seek new therapeutic approaches (pharmacological and non-pharmacological), and above all establish protocols that can guide the clinician from the stage of clinical suspicion to measures to prevent recurrence. It was the authors' aim to review the most significant literature on this subject, in order to produce a text that reflects the state of the art concerning PE and that can be used as a guide in the clinical approach to this pathology.

Diagnosis, Differential↗