Pulmonary embolism: the search continues

Abstract

Pulmonary thromboembolism (PTE) is one of the cardiovascular pathologies that put the life of our patients at greater risk. It is evident from recent registries that at least in the United States, with 600000 annual cases, PTE is more prevalent and produces a higher mortality rate than acute myocardial infarction with ST segment elevation (5% a7% vs. 10% a 15%). (1) Delay in the diagnosis is certainly involved in the unfavorable outcome of many patients, and once this is made, inadequate risk stratification. The causes are evident: one is the diagnostic difficulties of this disease, frequently present in patients with other pathologies with superposition of symptoms, such as respiratory disease, heart failure and cancer. (2) Another not lesser cause is the relative lack of knowledge we have of this disease, due to the scarce number of prospective studies performed with adequate technology, the reduced space it is dedicated in graduate and postgraduate study plans, and often in underdeveloped countries, the insufficient availability of adequate diagnostic methods. Once the diagnosis is confirmed, risk stratification is essential to determine the appropriate therapy, avoiding both insufficient treatments as excesses that might jeopardize the patients’s life. (3) Several studies have shown that patients with shock, sustained hypotension or syncope have elevated mortality, which according to the assessed case series varies between 15% and 50% and increases to 65% if they have suffered circulatory arrest. (4) It is agreed that these high risk patients must be referred without delay to high complexity units (ICUCCU) and are potential candidates to aggressive therapies: thrombolytics or mechanical thrombi treatment eventually associated with thrombolytics and performed in the hemodynamics laboratory. (2) On the other hand, hemodynamically stable patients ought to be adequately classified, firstly to decide where they should be treated and eventually if therapy should progress. Some authors, as Autjesky, (5) postulate that low risk patients may be treated at home or with brief hospitalizations at low complexity units. This recommendation is based on results (6) showing low mortality in these patients 1%.