Pulmoner Emboliye Güncel Yaklaşım

Abdullah Tekin

doi:10.17827/aktd.253565

Review

Current Approach to Pulmonary Embolism

Year 2016, Volume: 25 Issue: 4, 550 - 570, 31.12.2016

Abdullah Tekin

https://doi.org/10.17827/aktd.253565

Abstract

Pulmonary embolism is a relatively common cardiovascular emergency. Pulmonary embolism and deep venous thrombosis constitute one of the ‘big three’ cardiovascular killers along with myocardial infarction and stroke. The case fatality rate for pulmonary embolism exceeds the mortality rate for acute myocardial infarction. Thus, early diagnosis is fundemantal, since immediate treatment is highly effective. However, is pulmonary embolism a difficult diagnosis that might be missed because of non-specific clinical presentation. This review will address the current approach to pulmonary embolism except fot the treatment which will be a subject for a future article.

Keywords

Pulmonary embolism, deep vein thrombosis, venous thromboembolism

References

Güven Platformu. Ulusal Venöz Tromboembolizm Profilaksi ve Tedavi Kılavuzu. 2010
White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107:14-8.
Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007;98:756-64.
Kearon C, Akl EA. Duration of anticoagulant therapy for deep vein thrombosis and pulmonary embolism. Blood. 2014;123:1794–1801.
Anderson FA Jr., Spencer FA. Risk factors for venous thromboembolism. Circulation. 2003;107:19- 116.
Rogers MA, Levine DA, Blumberg N, Flanders SA, Chopra V, Langa KM. Triggers of hospitalization for venous thromboembolism. Circulation. 2012;125:2092-9.
Ku GH, White RH, Chew HK, Harvey DJ, Zhou H,WunT. Venous thromboembolism in patients with acute leukemia: incidence, risk factors, and effect on survival. Blood. 2009;113:3911-7.
Chew HK, Wun T, Harvey D, Zhou H, White RH. Incidence of venous thromboembolism and its effect on survival among patients with common cancers. Arch Intern Med. 2006;166:458-64.
Blom JW, Doggen CJ, Osanto S, Rosendaal FR. Malignancies, prothrombotic mutations, and the risk of venous thrombosis. JAMA. 2005;293:715-22.
Timp JF, Braekkan SK, Versteeg HH, Cannegieter SC. Epidemiology of cancer associated venous thrombosis. Blood. 2013;122:1712-23.
Blanco-Molina A, Rota LL, Di Micco P, Brenner B, Trujillo-Santos J, Ruiz-Gamietea A, et al. Venous thromboembolism during pregnancy, postpartum or during contraceptive use. Thromb Haemost. 2010;103:306-11.
Blanco-Molina A, Trujillo-Santos J, Tirado R, Can˜as I, Riera A, Valde´s M, et al. Venous thromboembolism in women using hormonal contraceptives. Findings from the RIETE Registry. Thromb Haemost. 2009;101:478-82.
Pomp ER, Lenselink AM, Rosendaal FR, Doggen CJ. Pregnancy, the postpartum period and prothrombotic defects: risk of venous thrombosis in the MEGA study. J Thromb Haemost. 2008;6:632-7.
Henriksson P, Westerlund E, Walle´n H, Brandt L, HovattaO, Ekbom A. Incidence of pulmonary and venous thromboembolism in pregnancies after in vitro fertilisation: cross sectional study. BMJ. 2013;346:e8632.
Sweetland S, Beral V, Balkwill A, Liu B, Benson VS, Canonico M, et al. Venous thromboembolism risk in relation to use of different types of postmenopausal hormone therapy in a large prospective study. J Thromb Haemost. 2012;10:2277-86.
Clayton TC, Gaskin M, Meade TW. Recent respiratory infection and risk of venous thromboembolism: case-control study through a general practice database. Int J Epidemiol.
Smeeth L, Cook C, Thomas S, Hall AJ, Hubbard R, Vallance P. Risk of deep vein thrombosis and pulmonary embolism after acute infection in a community setting. Lancet. 2006;367:1075-9.
Khorana AA, Kuderer NM, Culakova E, Lyman GH, Francis CW. Development and validation of a predictive model for chemotherapy-associated thrombosis. Blood. 2008;111:4902-7.
Piazza G, Goldhaber SZ. Venous thromboembolism and atherothrombosis: an integrated approach. Circulation. 2010;121:2146-50.
Severinsen MT, Kristensen SR, Johnsen SP, Dethlefsen C, Tjonneland A, Overvad K. Smoking and venous thromboembolism: a Danish follow-up study. J Thromb Haemost. 2009;7:1297-303.
Steffen LM, Cushman M, Peacock JM, Heckbert SR, Jacobs DR Jr., Rosamond WD et al. Metabolic syndrome and risk of venous thromboembolism: Longitudinal Investigation of Thromboembolism Etiology. J Thromb Haemost. 2009;7:746-51.
AgenoW, Becattini C, Brighton T, Selby R, Kamphuisen PW. Cardiovascular risk factors and venous thromboembolism: a meta-analysis. Circulation. 2008;117:93-102.
Kakkar VV, Howe CT, Flanc C, Clarke MB. Natural history of postoperative deep vein thrombosis. Lancet. 1969;2:230-2.
Dalen JE. Pulmonary embolism: what have we learned since Virchow? Natural history, pathophysiology, and diagnosis. Chest. 2002;122:1440-56.
Kearon C. Natural history of venous thromboembolism. Circulation. 2003;107:122-30.
Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest. 2002;121:877-905.
Konstantinides S. Pulmonary embolism: impact of right ventricular dysfunction. Curr Opin Cardiol. 2005;20:496-501.
Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J et al. A prediction rule to identify low-risk patients with pulmonary embolism. Arch Intern Med. 2006;166:169-75.
Laporte S, Mismetti P, De´cousus H, Uresandi F, Otero R, Lobo JL, et al. Clinical predictors for fatal pulmonary embolism in 15,520 patients with venous thromboembolism: findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) Registry. Circulation. 2008;117:1711-16.
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.
Miniati M, Monti S, Bottai M, Scoscia E, Bauleo C, Tonelli L, et al. Survival and restoration of pulmonary perfusion in a long-term follow-up of patients after acute pulmonary embolism. Medicine. (Baltimore). 2006;85:253-62.
Becattini C, Agnelli G, Pesavento R, Silingardi M, Poggio R, Taliani MR et al. Incidence of chronic thromboembolic pulmonary hypertension after a first episode of pulmonary embolism. Chest.
Moser KM, Fedullo PF, Littejohn JK, Crawford R. Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis. JAMA. 1994;271:223-5.
Kyrle PA, Rosendaal FR, Eichinger S. Risk assessment for recurrent venous thrombosis. Lancet. 2010;376:2032-9.
Zhu T, Martinez I, Emmerich J. Venous thromboembolism: risk factors for recurrence. Arterioscler Thromb Vasc Biol. 2009;29:298-310.
Heit JA. Predicting the risk of venous thromboembolism recurrence. Am J Hematol. 2012;87:63- 67.
Smulders YM. Pathophysiology and treatment of haemodynamic instability in acute pulmonary embolism: the pivotal role of pulmonary vasoconstriction. Cardiovasc Res. 2000;48:23-33.
Molloy WD, Lee KY, Girling L, Schick U, Prewitt RM. Treatment of shock in a canine model of pulmonary embolism. Am Rev Respir Dis. 1984;130:870-4.
Marcus JT, Gan CT, Zwanenburg JJ, Boonstra A, Allaart CP, Gotte MJ, et al. Interventricular mechanical asynchrony in pulmonary arterial hypertension: left-to-right delay in peak shortening is related to right ventricular overload and left ventricular underfilling. J Am Coll Cardiol. 2008;51:750-7.
Mauritz GJ, Marcus JT, Westerhof N, Postmus PE, Vonk-Noordegraaf A. Prolonged right ventricular post-systolic isovolumic period in pulmonary arterial hypertension is not a reflection of diastolic dysfunction. Heart. 2011;97:473-8.
Sergysels R. Pulmonary gas exchange abnormalities in pulmonary embolism. In: Morpurgo M, ed. Pulmonary Embolism. New York: Marcel Dekker, 1994;89-96.
Kasper W, Geibel A, Tiede N, Just H. Patent foramen ovale in patients with haemodynamically significant pulmonary embolism. Lancet. 1992;340:561-4.
Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N et al. ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society. Eur Heart J. 2014;35:3033-69.
Pollack CV, Schreiber D, Goldhaber SZ, Slattery D, Fanikos J, O’Neil BJ et al. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the RealWorld Registry). J Am Coll Cardiol. 2011;57:700-6.
Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129:997-1005
Thames MD, Alpert JS, Dalen JE. Syncope in patients with pulmonary embolism. JAMA. 1977;238:2509-11.
Stein PD, Henry JW. Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes. Chest. 1997;112: 974-9.
Rodger MA, Carrier M, Jones GN, Rasuli P, Raymond F, Djunaedi H et al. Diagnostic Value of Arterial Blood Gas Measurement in Suspected Pulmonary Embolism. Am J Respir Crit Care Med. 2000;162:2105-8.
Elliott CG, Goldhaber SZ, Visani L, DeRosa M. Chest radiographs in acute pulmonary embolism. Results from the International Cooperative Pulmonary Embolism Registry. Chest. 2000;118:33-8.
Geibel A, Zehender M, Kasper W, Olschewski M, Klima C, Konstantinides SV. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. Eur Respir J. 2005;25:843-8.
Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000; 83:416-20.
Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med.
Righini M, Goehring C, Bounameaux H, Perrier A. Effects of age on the performance of common diagnostic tests for pulmonary embolism. Am J Med. 2000;109:357-61.
Schouten HJ, Geersing GJ, Koek HL, Zuithoff NP, Janssen KJ, Douma RA et al. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. BMJ. 2013;346:f2492.
Ghaye B, Szapiro D, Mastora I, Delannoy V, Duhamel A, Remy J et al. Peripheral pulmonary arteries: how far in the lung does multi-detector row spiral CT allow analysis? Radiology. 2001;219:629-36.
Winer-Muram HT, Rydberg J, Johnson MS, Tarver RD, Williams MD, Shah H et al. Suspected acute pulmonary embolism: evaluation with multi-detector row CT versus digital subtraction pulmonary arteriography. Radiology. 2004;233:806-15.
Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354:2317-27.
Perrier A, Roy PM, Sanchez O, Le Gal G, Meyer G, Gourdier AL et al. Multidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med. 2005;352:1760-8.
van Belle A, Buller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295:172-9.
Anderson DR, Kahn SR, Rodger MA, Kovacs MJ, Morris T, Hirsch A et al. Computed tomographic pulmonary angiography vs. ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA. 2007;298:2743-53.
Righini M, Le Gal G, Aujesky D, Roy PM, Sanchez O, Verschuren F et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008;371:1343-52.
Carrier M, Righini M, Wells PS, Perrier A, Anderson DR, Rodger MA et al. Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. J Thromb Haemost. 2010;8:1716-22.
Roach PJ, SchembriGP, Bailey DL. V/Q scanning using SPECTand SPECT/CT. J Nucl Med. 2013;54:1588-96.
PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolismdiagnosis (PIOPED). JAMA.
Sostman HD, Stein PD, Gottschalk A, Matta F, Hull R, Goodman L. Acute pulmonary embolism: sensitivity and specificity of ventilation-perfusion scintigraphy in PIOPED II study. Radiology. 2008;246:941-6.
Reinartz P, Kaiser HJ, Wildberger JE, Gordji C, Nowak B, Buell U. SPECT imaging in the diagnosis of pulmonary embolism: automated detection of match and mismatch defects by means of image- processing techniques. J Nucl Med. 2006;47:968-73.
Collart JP, Roelants V, Vanpee D, Lacrosse M, Trigaux JP, Delaunois L et al. Is a lung perfusion scan obtained by using single photon emission computed tomography able to improve the radionuclide diagnosis of pulmonary embolism? Nucl Med Commun. 2002;23:1107-13.
Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000;101:2817-22.
Kurzyna M, Torbicki A, Pruszczyk P, Burakowska B, Fijałkowska A, Kober J et al. Disturbed right ventricular ejection pattern as a new Doppler echocardiographic sign of acute pulmonary embolism. Am J Cardiol. 2002;90:507–11.
Roy PM, Colombet I, Durieux P, Chatellier G, Sors H, Meyer G. Systematic review and meta- analysis of strategies for the diagnosis of suspected pulmonary embolism. BMJ. 2005;331:259.
Kucher N, Luder CM, Dornhofer T, Windecker S, Meier B, Hess OM. Novel management strategy for patients with suspected pulmonary embolism. Eur Heart J. 2003;24:366-76.
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;98:891-9.
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;129:1044-9.
Le Gal G, Righini M, Sanchez O, Roy PM, Baba-Ahmed M, Perrier A et al. A positive compression ultrasonography of the lower limb veins is highly predictive of pulmonary embolism on computed tomography in suspected patients. Thromb Haemost. 2006;95:963-6.
Elias A, Colombier D, Victor G, Elias M, Arnaud C, Juchet H et al. Diagnostic performance of complete lower limb venous ultrasound in patients with clinically suspected acute pulmonary embolism. Thromb Haemost. 2004;91:187-95.
Kline JA, Webb WB, Jones AE, Hernandez-Nino J. Impact of a rapid rule-out protocol for pulmonary embolism on the rate of screening, missed cases, and pulmonary vascular imaging in an urban US emergency department. Ann Emerg Med. 2004;44:490-502.
Brenner DJ, Hall EJ. Computed tomography: an increasing source of radiation exposure. N Engl J Med. 2007;357:2277-84.
Chan CM, Woods C, Shorr AF. The validation and reproducibility of the pulmonary embolism severity index. J Thromb Haemost. 2010;8:1509–14.
Donze J, Le Gal G, Fine MJ, Roy PM, Sanchez O, Verschuren F, Cornuz J et al. Prospective validation of the Pulmonary Embolism Severity Index. A clinical prognostic model for pulmonary embolism. Thromb Haemost. 2008;100:943-8.
Wicki J, Perrier A, Perneger TV, Bounameaux H, Junod AF. Predicting adverse outcome in patients with acute pulmonary embolism: a risk score. Thromb Haemost. 2000;84:548-52.
Kreit JW. The impact of right ventricular dysfunction on the prognosis and therapy of normotensive patients with pulmonary embolism. Chest. 2004;125:1539-45.
Coutance G, Cauderlier E, Ehtisham J, Hamon M, Hamon M. The prognostic value of markers of right ventricular dysfunction in pulmonary embolism: a meta-analysis. Crit Care. 2011;15:R103.
Kucher N, Goldhaber SZ. Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Circulation. 2003;108:2191-4.
Lankeit M, Jimenez D, Kostrubiec M, Dellas C, Kuhnert K, Hasenfuss G et al. Validation of N- terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism. Eur Respir J. 2014;43:1669-77.
Vuilleumier N, Le Gal G, Verschuren F, Perrier A, Bounameaux H, Turck N et al. Cardiac biomarkers for risk stratification in non-massive pulmonary embolism: a multicenter prospective study. J Thromb Haemost. 2009;7:391-8.
Coma-Canella I, Gamallo C, Martinez Onsurbe P, Lopez-Sendon J. Acute right ventricular infarction secondary to massive pulmonary embolism. Eur Heart J. 1988;9:534-40.
Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation. 2007;116:427-33.
Boscheri A, Wunderlich C, Langer M, Schoen S, Wiedemann B, Stolte D et al. Correlation of heart- type fatty acid-binding protein with mortality and echocardiographic data in patients with pulmonary embolism at intermediate risk. Am Heart J. 2010;160:294-300.
Dellas C, Puls M, Lankeit M, Schafer K, Cuny M, Berner M et al. Elevated heart-type fatty acid- binding protein levels on admission predict an adverse outcome in normotensive patients with acute pulmonary embolism. J Am Coll Cardiol. 2010;55:2150-7.
Correspondence Address / Yazışma Adresi Abdullah Tekin
Başkent Üniversitesi Tıp Fakültesi
Kardiyoloji Anabilim Dalı, Ankara, Turkey
e-mail: tekincardio@yahoo.com
Geliş tarihi/ Received: 03.03.2016
Kabul tarihi/Accepted: 20.04.2016