Abstract
Venous thromboembolism (VTE), the third most frequent acute cardiovascular syndrome, may cause life-threatening complications and imposes a substantial socio-economic burden. During the past years, several landmark trials paved the way towards novel strategies in acute and long-term management of patients with acute pulmonary embolism (PE). Risk stratification is increasingly recognized as a cornerstone for an adequate diagnostic and therapeutic management of the highly heterogeneous population of patients with acute PE. Recently published European Guidelines emphasize the importance of clinical prediction rules in combination with imaging procedures (assessment of right ventricular function) and laboratory biomarkers (indicative of myocardial stress or injury) for identification of normotensive PE patients at intermediate risk for an adverse short-term outcome. In this patient group, systemic full-dose thrombolysis was associated with a significantly increased risk of intracranial bleeding, a complication which discourages its clinical application unless hemodynamic decompensation occurs. A large-scale clinical trial program evaluating new oral anticoagulants in the initial and long-term treatment of venous thromboembolism showed at least comparable efficacy and presumably increased safety of these drugs compared to the current standard treatment. Research is continuing on catheter-directed, ultrasound-assisted, local, low-dose thrombolysis in the management of intermediate-risk PE.
Highlights
INITIAL RISK STRATIFICATIONVenous thromboembolism (VTE) is the third most frequent acute cardiovascular syndrome in industrialized countries, accounting for approximately 100 to 200 new cases per 100,000 population per year.[1,2] As the incidence of VTE increases in an exponential manner with age, ongoing demographic changes will result in a growing number of patients suffering from the acute and long-term sequelae of VTE in the future.[3]
One-third of all patients with VTE present with acute pulmonary embolism (PE), with or without clinically evident deep vein thrombosis; acute PE accounts for the majority of VTE-associated hospitalizations and deaths.[2]
The non-specific signs and symptoms of acute PE frequently hamper diagnosis, resulting in an underestimation of the actual frequency of disease. This is supported by data derived from epidemiologic models suggesting that only 7% of patients dying early in the course of acute PE are diagnosed correctly during life.[2]
Summary
Venous thromboembolism (VTE) is the third most frequent acute cardiovascular syndrome in industrialized countries, accounting for approximately 100 to 200 new cases per 100,000 population per year.[1,2] As the incidence of VTE increases in an exponential manner with age, ongoing demographic changes will result in a growing number of patients suffering from the acute and long-term sequelae of VTE in the future.[3]. Less than 5% of patients with acute PE present with hemodynamic compromise (shock or persistent arterial hypertension) on admission due to clinically overt RV failure.[6] This condition is associated with an estimated PE-related early mortality risk of at least 15%, a fact which mandates emergency advanced medical care.[7] initial triage of patients with suspected acute PE should be based upon the assessment of the hemodynamic (clinical) stability allowing for a simplified classification into a high-risk or a nonhigh-risk group This approach allows all subsequent diagnostic and therapeutic strategies to be adapted to the acuteness and severity of the clinical situation, maximizing efficiency of resource utilization and potentially saving lives. As the sensitivity and negative predictive value of ELISA-based D-dimer assays are high,[34,35] PE can be safely ruled out in patients with low or intermediate clinical probability of the disease and a negative D-dimer test These patients can be left untreated (i.e. without anticoagulation), as proven in outcome studies and a meta-analysis which indicated a 3-month thromboembolic risk below 1%.36–41. Compression ultrasound sonography visualizing proximal deep vein thrombosis confirms PE without the need for further imaging tests
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