Risk Stratification for Acute Pulmonary Embolism

Abstract

Pulmonary embolism (PE) is a commonly encountered condition in the medical and surgical intensive care unit. Whereas overall mortality in those with PE is 5% to 15% in the first few months after diagnosis due to a combination of underlying medical conditions, recurrent venous thromboembolism and right heart failure, outcomes after acute PE vary substantially across subgroups. 1 Agnelli G. Becattini C. Acute pulmonary embolism. N Engl J Med. 2010; 363: 266-274 Crossref PubMed Scopus (348) Google Scholar , 2 Spencer F.A. Goldberg R.J. Lessard D. et al. Factors associated with adverse outcomes in outpatients presenting with pulmonary embolism: he Worcester Venous Thromboembolism Study. Circ Cardiovasc Qual Outcomes. 2010; 3: 390-394 Crossref PubMed Scopus (45) Google Scholar , 3 Aujesky D. Obrosky D.S. Stone R.A. et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Resp Crit Care Med. 2005; 172: 1041-1046 Crossref PubMed Scopus (806) Google Scholar , 4 Goldhaber S.Z. Visani L. De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999; 353: 1386-1389 Abstract Full Text Full Text PDF PubMed Scopus (2372) Google Scholar , 5 Kasper W. Konstantinides S. Geibel A. et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol. 1997; 30: 1165-1171 Abstract Full Text Full Text PDF PubMed Scopus (850) Google Scholar Patients who present with shock suffer from an approximate 25% to 50% short-term mortality rate, whereas those with preserved blood pressure at presentation experience only a 2% to 5% risk of death. 4 Goldhaber S.Z. Visani L. De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999; 353: 1386-1389 Abstract Full Text Full Text PDF PubMed Scopus (2372) Google Scholar , 5 Kasper W. Konstantinides S. Geibel A. et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol. 1997; 30: 1165-1171 Abstract Full Text Full Text PDF PubMed Scopus (850) Google Scholar , 6 Buller H.R. Davidson B.L. Decousus H. et al. Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med. 2003; 349: 1695-1702 Crossref PubMed Scopus (821) Google Scholar , 7 Simonneau G. Sors H. Charbonnier B. et al. A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism The THESEE Study Group. Tinzaparin ou Heparin Standard: Evaluations dans l'Embolie Pulmonaire. N Engl J Med. 1997; 337: 663-669 Crossref PubMed Scopus (819) Google Scholar Despite this understanding of the spectrum of prognoses in those with acute PE, there remains much uncertainty in how best to align the risk of adverse outcome in acute PE with the appropriate intensity of therapeutic intervention. Apart from those who present in shock and immediately declare their prognosis, which patients with acute PE are at low risk of adverse outcomes and do not require a higher level of care? Which patients are at an elevated risk of clinical deterioration and should be treated in the intensive care unit and perhaps considered for thrombolytic therapy?