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Diagnostic work up of pulmonary embolism (PE) should be based on well-described clinical prediction scores (Wells score, Geneva score, and so forth). Every patient with a high likelihood of having PE should be started on prompt anticoagulation if there is no absolute contraindication for it.
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Newer oral anticoagulants are the preferred agent of choice over vitamin K antagonists, except in cancer patients and patients with antiphospholipid antibody syndrome.
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Patients with submassive or massive PE
Pulmonary Embolism
Section snippets
Key points
Classification of pulmonary embolism
PE can be classified based on clot location or hemodynamic compromise. Saddle PE refers to a clot located in the main PA or bifurcation. Saddle PE does not necessarily translate into a massive PE (defined later). Mortality rate related to saddle PE is close to 5%.31 Likewise, lobar, segmental, and subsegmental PE describe clot location in the pulmonary arterial branches corresponding to the anatomic lung lobe, segment, or subsegment respectively. Terms, such as nonmassive PE and major PE, are
Diagnosis and evaluation
Diagnosis of PE can be challenging because symptoms are nonspecific. Nonetheless, the classic presenting symptoms are pleuritic chest pain (39%) and dyspnea at rest (50%).29 Hemoptysis also is a common presenting complaint due to pulmonary infarction. Hemoptysis can be seen in up to 20% of patients with PE. Hemoptysis in setting of PE is not an absolute indication to stop anticoagulation. Syncope can be an initial presentation of hemodynamically significant PE. It is also important to elicit
D-Dimer
D-dimer is a fibrin degradation product. It is used as a surrogate marker of fibrinolysis and is expected to be elevated during a thrombotic event. Measured using ELISA, a normal level is less than 500 ng/mL in most laboratories. D-dimer can be elevated in various conditions, such as pregnancy, postoperative state, and malignancy, which lowers its specificity. It is also known to have levels that increase with age and thus the levels are adjusted for this parameter.36 In combination with a low
Venous Ultrasound Duplexes
Ultrasound of the lower extremity is useful when evaluating a patient for PE. It is relatively quick and does not require radiation. The goal is to find noncompressible veins, suggesting vessel occlusion. Ultrasonography is not used alone, however; rather, it supplements the diagnosis of PE by identifying a source. A negative venous ultrasound does not rule out the possibility of PE.
Management of pulmonary embolism
All patients with high pretest probability or confirmed PE should be initiated on anticoagulation. Empiric early anticoagulation has been associated with decreased mortality for patients with acute PE.49, 50 Mainstay therapy for patients being admitted is unfractionated heparin that is administered as an 80 U/kg bolus followed by an infusion at 18 U/kg/h bolus or a weight-based dosing for low-molecular-weight heparin (LMWH), such as enoxaparin. Studies have shown there is no difference between
Post–pulmomary embolism discharge
Every patient with VTE should have close outpatient follow-up.71 An attempt should be made to determine the etiology of PE, which sometimes can be difficult in the inpatient setting. Hypercoagulable work-up should be considered on individualized basis and after discussing with patients. Age-appropriate cancer screening should be performed. Modifiable risk factors for VTE like smoking cessation and weight reduction can be addressed on outpatient follow-up visits.72 It is also of paramount
Summary
The authors conclude this review with the following salient points for readers:
- 1.
The authors recommend using predictive score (Wells, Geneva, or PERC) for VTE before ordering CTPA.
- 2.
CTPA remains the gold standard for diagnosis of PE.
- 3.
High pretest probabilities for PE and low bleeding risk should prompt empiric anticoagulation while waiting for confirmative testing.
- 4.
Treatment decisions for PE should be based on hemodynamic impact, not merely a clot location and risk stratification.
- 5.
Echocardiography,
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Disclosure Statement: None of the listed authors have any commercial or financial conflicts of interest and any funding sources pertaining to topic in discussion.