Pulmonary Embolism Syndrome Research Articles

Pulmonary embolism detection without intravenous contrast using electron density and Z-effective maps from dual-energy CT

Abstract Purpose This study aims to evaluate the feasibility of using electron density (ED) maps combined with Z-effective (Zeff) images obtained from unenhanced dual-layer dual-energy CT (dl-DECT) scans of the chest for the detection of pulmonary embolism (PE). Materials and methods A retrospective analysis was conducted on consecutive patients who underwent for contrast-enhanced chest CT (CECT) clinically suspected of PE or acute aortic syndrome. These scans were performed on a single dl-DECT scanner between October 2021 and November 2023. To distinguish emboli from circulating blood, color-coded maps were generated from the ED dataset superimposed on Zeff images, which were acquired from the unenhanced phase. Two radiologists with different levels of expertise independently assessed the presence of PE in the generated ED-Zeff maps, blinded to CECT results, which served as the reference standard. Diagnostic accuracy of ED-Zeff maps was assessed for each reader. Results The final study cohort comprised 150 patients, with 92 males (mean age: 68 ± 10 years, range: 47-93 years) and 58 females (mean age: 66 ± 15 years, range 38-89 years). ED-Zeff maps demonstrated high diagnostic performance, yielding accuracy, sensitivity, and specificity, respectively, of 86.67% (113/150, 95% CI, 80.16%-91.66%), 85% (17/20, 95% CI, 79.89%-92.19%), and 86.92% (113/130, 95% CI, 79.89%-92.19%). Ed-Zeff maps were able to identify PE in 85% of positive cases. Cohen’s kappa coefficient indicated excellent intra- and interobserver agreement (κ ≥ 0.9). Conclusion ED maps combined with Zeff images from unenhanced dl-DECT scans represent a feasible tool for detecting PE and may prove useful in evaluating patients with contraindications to iodinated contrast.

PB0481 A Randomized Controlled Trial to Evaluate the Efficacy of an 8-Week Standardized Exercise Training Program for Preventing Post- Pulmonary Embolism Syndrome: Rationale & Design of the PE@HOME Study

PB0481 A Randomized Controlled Trial to Evaluate the Efficacy of an 8-Week Standardized Exercise Training Program for Preventing Post- Pulmonary Embolism Syndrome: Rationale & Design of the PE@HOME Study

Impact of Alteplase on Mortality in Critically Ill Patients with COVID-19 and Pulmonary Embolism.

COVID-19 is an independent risk factor for pulmonary embolism (PE). Little is known about alteplase therapy in this patient group. A retrospective study analyzed 74 patients with PE and acute respiratory distress syndrome (ARDS) due to COVID-19 who were hospitalized in the intensive care unit in 2021. Patients with or without confirmed right heart thrombi (RHT) were treated with unfractionated heparin or alteplase. The mortality rate in patients with RHT treated with heparin was 100% compared to 37.9% and 55.2% in those treated with alteplase without RHT and alteplase with RHT, respectively. The risk of death in the alteplase group increased with delayed thrombolysis (p = 0.009, odds ratio (OR) = 1.73 95% CI (confidence interval) 1.14-2.62), increased D-dimer concentration (p = 0.02, OR = 1.43 95% CI 1.06-1.93), and decreased PaO2/FiO2 ratio (p = 0.001, OR = 0.56 95% CI 0.41-0.78). The receiver operating characteristic method determined that a 1-day delay in thrombolytic treatment, D-dimer concentration >5.844 mg/L, and PaO2/FiO2 <144 mmHg predicted a fatal outcome. The risk of death in patients with severe COVID-19 with ARDS and PE increases with higher D-dimer levels, decreased PaO2/FiO2, and delayed thrombolytic treatment. Thrombolysis seems to be treatment of choice in severe COVID-19 with PE and RHT. It should be carried out as soon as possible after the diagnosis is established.

P2. FAT GRAFT PULMONARY EMBOLISM: IN FAVOUR OF A LYMPHATIC ROUTE

PURPOSE: Fat Pulmonary Embolism Syndrome (F-PES) complicates high-volume fat grafting. Adipocyte disruption generates triglyceride (TGC) oil dispersed in lipoaspirate (lipocrit). TGC plasma concentration ([TGC]p) was compared with lipocrit during liposuction-lipografting procedures. 1 buttock grafting case suffered a F-PES that required ICU support. METHODS: n=27 (19 breast, 8 buttocks) lipocrit recorded and ([TGC]p) measured in peripheral blood samples preoperatively, intra and 24h postoperatively. F-PES patient underwent right subclavian vein access (SVC) and Inferior Vena Cava (IVC) at ICU admission RESULTS: Lipocrit (200-600 cc graft volume) ranged 19-27%.Peripheral [TGC]p pre-, intra- post- and at 24h displayed no significant differences for all cases. In the F-PES case, SVC drawn [TGC]p was 7-fold higher than that from simultaneously drawn IVC or peripheral samples and returned to normal peripheral levels 48 h later. These unexpected data prompted measurement of:Critical Micelle Concentration (CMC) of fat graft oil when mixed in either lymphatic (chylous, CMCc) or plasmatic (CMCp) fluids. CMCp was consistently higher than CMCc (CMCc=110 mg/dL, CMCp=320 mg/dL, n=17, P<0.001).Interstitial Pressures (IP) both intramuscular (im) and subcutaneous (sc) at recipient sites. IPsc raised to pressures below 50 mmHg and returned to baseline within 24 h. IPim raised above 50 mmHg and persisted CONCLUSION: F-PES appears associated to increased [TGC]p detectable at the SVC only. TGC micelle formation is thermodynamically adverse in plasma versus chyle, suggesting a preferential lymphatic uptake of grafted oil at the recipient site. This lymphatic uptake could be favored when graft oil is implanted im, where IP-im reach pressures that prevent venous drainage.

Pulmonary rehabilitation to improve physical capacity, dyspnea, and quality of life following pulmonary embolism (the PeRehab study): study protocol for a two-center randomized controlled trial

BackgroundRecently, a large group of patients with persistent dyspnea, poor physical capacity, and reduced health-related quality of life (HRQoL) following pulmonary embolism (PE) has been identified and clustered under the name “post pulmonary embolism syndrome” (PPS). These patients seem good candidates for pulmonary rehabilitation. The aim of the study is to explore whether a pulmonary rehabilitation program can improve physical capacity, dyspnea, and HRQoL in PPS patients.MethodsA two-center randomized controlled trial (RCT) is being performed at Østfold Hospital and Akershus University Hospital in Norway. Patients with PPS are 1:1 randomized into an intervention or a control group. The intervention consists of a supervised, outpatient rehabilitation program twice weekly (1 h) for 8 weeks provided by experienced physiotherapists. The intervention involves individually adapted exercises based on existing pulmonary rehabilitation programs (relaxation, interval, and resistance training), and an educational session including topics such as normal anatomy and physiology of the respiratory and circulatory system, information on PE/PPS, breathing strategies, and benefits of exercise/physical activity. Patients randomized to the control group receive usual care without specific instructions to exercise.Participants in the intervention and control groups will be compared based on assessments conducted at baseline, 12 weeks, and 36 weeks after inclusion using the incremental shuttle walk test (primary outcome) and endurance shuttle walk test (exercise capacity), Sensewear activity monitor (daily physical activity), the modified Medical Research Council scale, the Shortness of Breath Questionnaire (dyspnea), and EQ-5D-5L and the Pulmonary Embolism Quality of Life Questionnaire (HRQoL).Recruitment of 190 patients is currently ongoing.DiscussionResults from this study may provide a currently untreated group of PPS patients with an effective treatment resulting in reduced symptoms of dyspnea, improved exercise capacity, and better HRQoL following PE.Trial registrationClinical Trials NCT03405480. Registered prospectively on September 2017.Protocol version 1 (from original protocol September 2017).The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 1).

Difficult Diagnoses in Maternal Death: The Negative Maternal Autopsy

A proportion of mothers who die during pregnancy, delivery or some time post-partum, have no clear-cut cause of death despite autopsy examination. Such ‘negative’ autopsies cause pathologists, and all involved in the mother’s care, much concern. They illustrate the frontiers of what is known about why and how critical organs fail, and highlight the variation in the detail to which pathologists investigate maternal deaths. This review is intended for obstetricians, to illustrate the utility and some limitations of autopsy analysis of maternal death. The major scenarios of maternal death where autopsy reveals nothing or only confusing and subtle abnormal morphologies are considered. These include deaths under general and spinal anaesthesia, pulmonary embolism syndromes (air, fat and amniotic fluid), pre-eclampsia-associated deaths, and cardiac deaths including the SADS/MNH syndrome (sudden arrhythmic cardiac death with a morphologically normal heart). Key to the resolution of these post-mortem diagnostic problems is complete gross and histological examination at autopsy, appropriate additional analysis of body fluids and, in some cases, DNA analysis. All this to be correlated with the clinical circumstances and – critically – the patient’s physiological data available around the time the death. Here, a multi-disciplinary input from experts in obstetrics, medicine, intensive care and anaesthesia is invaluable to narrow down the possible pathogeneses and make as accurate a consensus diagnosis as is possible. A major contribution of the autopsy in such cases to exclude alternative possible clinical pathologies. Newer post-mortem examination techniques, such as cadaveric CT scanning, could prove helpful in the future. It is likely that there are clinico-pathological syndromes in maternal death that still await formal identification and characterisation.

“The post-pulmonary syndrome - results of echocardiographic driven follow up after acute pulmonary embolism”

IntroductionThe concept of post Pulmonary Embolism syndrome includes various combinations of functional, haemodynamic or imaging abnormalities in patients after pulmonary embolism (PE). Although residual obstruction of pulmonary vascular bed is suggested to be a major cause of post Pulmonary Embolism syndrome (post-PE syndrome) other cardiopulmonary abnormalities can be responsible for functional impairment. Therefore, we analyzed the frequency of post-PE syndrome and its potential causes. Material and methodsWe report data of consecutive 845 PE survivors (468 F, aged 62 ± 18 yrs) who were anticoagulated, and followed for at least 6 months. All symptomatic subjects at follow up underwent diagnostic workup. Results35% (290/845) of PE survivors recovered functionally, while 65% patients reported a decreased exercise tolerance compatible with post-PE syndrome. One hundred and five symptomatic cases were lost to follow up. After diagnostic workup, chronic thromboembolic pulmonary hypertension (CTEPH) was diagnosed in 38 of 450 (8.4%) symptomatic subjects and chronic thromboembolic pulmonary disease (CTED) was diagnosed in 15/450 (3.3%) of them. Chronic heart failure with reduced ejection fraction (EF) was found in 6.9% (31/450) of patients and 154 patients (34.2%) had leftsided diastolic dysfunction. Valve heart disease was detected in 6.2% (28/450), atrial fibrillation in 31/450 (6.9%), Other causes of reduced exercise tolerance include coronary artery disease in 31/450 (6.9%), pulmonary disease 42/450 (9.3%), morbid obesity 15/450 (3.3%), neoplasms 15/450 (3.3%), psychiatric disorders 1%, rheumatoid disease 1%, anemia 1%. ConclusionsApproximately 65% of PE survivors report functional impairment, despite at least 6 months of anticoagulation. Persistent pulmonary artery thromboemboli resulting in CTEPH or CTED were detected in 7.2% of PE survivors and 11.8% of symptomatic patients. Leftsided diastolic dysfunction was the most prevalent echocardiographic abnormality, and remained the most common cause of functional limitation affected 34.2% of symptomatic cases.

The Post–Pulmonary Embolism Syndrome: Real or Ruse?

The Post–Pulmonary Embolism Syndrome: Real or Ruse?

Fat Tissue Pulmonary Embolism Syndrome

Recently there have been cases reported that involve fat tissue embolization to the lung. The author has collected 7 total cases and no patient has survived. The cases are all presented in as much detail as possible with the information available. The anatomical explanation of embolization is described as well as the clinical manifestations and possible means of reducing the risk.

Coincidence of Malignancy and Congenital Thrombophilia as the Cause of Deep Venous Thrombosis - Case Report and Review of the Literature

Abstract Introduction: Deep venous thrombosis (DVT, phlebothrombosis) is a very important clinical problem with its resultant fatal pulmonary embolism (PE) as one of the possible consequences. Factor V Leiden (FV Leiden) is a genetic disorder characterized by a poor anticoagulant response to activated protein C (APC) and an increased risk of venous thromboembolism (VTE). Homozygous carriers of the FV Leiden mutation are estimated to have an 80-fold increased lifetime relative risk of VTE. Most homozygous carriers present with VTE before 40 years of age, but some can live thrombosis-free until the sixth or seventh decade of life or even remain asymptomatic for life. Case-controlled studies of patients with cancer revealed a four-fold increase in thromboembolic occurrence in acute leukaemia, with the risk of thrombosis persisting even after remission of the disease. Case Report: The authors present a case report of the 61-year-old patient with leukaemic transformation of myelodysplastic syndrome (MDS) to acute myeloid leukaemia (AML) and development of DVT of the left leg (LL) as the first clinical manifestation of homozygous FV Leiden carrier. Due to his diagnosis it was not possible to indicate surgical treatment of DVT. After initial treatment with subcutaneous low molecular weight heparin (LMWH) and continuous intravenous application of unfractionated heparin (UFH) the deficiency of antithrombin III (AT III) potentiating the persistence of his hypercoagulable state developed. Treatment with the new oral anticoagulant - rivaroxaban, vasoprotective and antithrombotic drugs in the combination with mechanical methods of VTE prophylaxis led to a reduction in edema of left thigh and calf by 3.5 cm and 4 cm, respectively. Son of the patient experienced DVT at the age of 27 years, too. Conclusion: In this report, we describe a case of the patient with DVT during the leukaemic transformation of MDS to AML as a relatively late first clinical manifestation of homozygous FV Leiden mutation. At the same time the article deals with the clinical aspects of discussed thrombophilia in the relatives of the patient, as well as with the etiopathogenesis, pharmacologic treatment options and possible complications of DVT (PE, pulmonary hypertension and post-thrombotic syndrome).

Deep Vein Thrombosis and Pulmonary Embolism

Venous thromboembolism (VTE) is a dynamic disease process that results in two distinct but related conditions: deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT is thrombus formation that most commonly, but not exclusively, affects the lower limbs. The estimated incidence of symptomatic DVT is 1 per 1000 per year in the general population of the UK; however, it is often asymptomatic and thus the overall incidence is likely to be higher. Significant complications arising from DVT include PE (often from an asymptomatic DVT) and post-thrombotic syndrome (PTS), which occurs in 30% of patients with proven DVT. There is significant morbidity and mortality associated with both of these conditions, but with timely diagnosis and treatment much of this is potentially preventable. Therefore, a high index of suspicion within primary care is needed to ensure early diagnosis and appropriate treatment. This article aims to highlight the current evidence-based management of DVT and PE, from clinical suspicion to treatment.

Venous thromboembolism prophylaxis: do trial results enable clinicians and patients to evaluate whether the benefits justify the risk? proceedings of an ad hoc working group meeting

Venous thromboembolism prophylaxis: do trial results enable clinicians and patients to evaluate whether the benefits justify the risk? proceedings of an ad hoc working group meeting

Pulmonary Embolism Incidence and Fatality Trends in Chinese Hospitals from 1997 to 2008: A Multicenter Registration Study

BackgroundThere has not been sufficient evidence to support the Asians being less susceptible to pulmonary embolism (PE) than other ethnicities, because the prevalence of PE/deep venous thrombosis (DVT) in different racial and ethnic groups has not been carefully studied until recently except in Caucasians. To test the hypothesis that the Chinese population has a lower risk for PE, this study comprehensively assessed the hospital-based incidence and case fatality rates for PE during the 1997–2008 in China.MethodsA registration study of patients with suspected PE syndromes admitted to 60 level-3 hospitals involved in the National Cooperative Project for the Prevention and Treatment of Venous Thromboembolism (NCPPT) was conducted from January 1997 to December 2008. The only exclusion criterion was an age of less than 18 years. Helical computed tomography scan, ventilation-perfusion lung scintigraphy or pulmonary angiography was carried out before or after hospitalization. All images were reviewed and evaluated independently by two specialists.ResultsA total of 18,206 patients were confirmed with PE from 16,972,182 hospital admissions. The annual incidence was 0.1% (95% CI: 0.1% to 0.2%). The overall incidence of PE in male patients (0.2%, 95% CI: 0.1% to 0.3%) was higher than that in female patients (0.1% and 95% CI: 0.0% to 0.1%). An increasing incidence gradient for PE was noticed from Southern to Northern China. In addition, the case fatality rate was apparently decreasing: 25.1% (95% CI: 16.2% to 36.9%) in 1997 to 8.7% (95% CI: 3.5% to 15.8%) in 2008.ConclusionsOur findings suggest the relatively stable PE incidence and decreasing fatality trends in Chinese hospitals may be partially attributable to the implementation of the NCCPT and suggest the government should reevaluate the severity of PE so that health resources for the prevention, diagnosis and treatment of PE could be used to their fullest.

Triple rule-out CT in the emergency department: protocols and spectrum of imaging findings

Triage decisions in patients suffering from acute chest pain remain a challenge. The patient's history, initial cardiac enzyme levels, or initial electrocardiograms (ECG) often do not allow selecting the patients in whom further tests are needed. Numerous vascular and non-vascular chest problems, such as pulmonary embolism (PE), aortic dissection, or acute coronary syndrome, as well as pulmonary, pleural, or osseous lesions, must be taken into account. Nowadays, contrast-enhanced multi-detector-row computed tomography (CT) has replaced previous invasive diagnostic procedures and currently represents the imaging modality of choice when the clinical suspicion of PE or acute aortic syndrome is raised. At the same time, CT is capable of detecting a multitude of non-vascular causes of acute chest pain, such as pneumonia, pericarditis, or fractures. Recent technical advances in CT technology have also shown great advantages for non-invasive imaging of the coronary arteries. In patients with acute chest pain, the optimization of triage decisions and cost-effectiveness using cardiac CT in the emergency department have been repetitively demonstrated. Triple rule-out CT denominates an ECG-gated protocol that allows for the depiction of the pulmonary arteries, thoracic aorta, and coronary arteries within a single examination. This can be accomplished through the use of a dedicated contrast media administration regimen resulting in a simultaneous attenuation of the three vessel territories. This review is intended to demonstrate CT parameters and contrast media administration protocols for performing a triple rule-out CT and discusses radiation dose issues pertinent to the protocol. Typical life-threatening and non-life-threatening diseases causing acute chest pain are illustrated.

Prolonged thromboprophylaxis with Dalteparin during immobilization after ankle fracture surgery: A randomized placebo-controlled, double-blind study

Background Skeletal trauma and immobilization are well-known risk factors for deep vein thrombosis (DVT) and pulmonary embolism (PE). While prophylaxis against thromboembolic complications has become routine after major orthopedic surgery, whether or not prophylaxis after minor surgery and lower limb immobilization is necessary is still under debate.Methods In a double-blind, placebo-controlled study, 272 consecutive patients were randomized to receive either thromboprophylaxis with Dalteparin (n = 136) or placebo (n = 136) for 5 weeks after ankle fracture surgery. All patients received 1 week of initial treatment with Dalteparin before randomization. A unilateral phlebography was performed when the cast was removed.Results The overall incidence of DVT was 21% (95% CI: 13–29%) in the Dalteparin group and 28% (CI: 19– 37%) in the placebo group (risk ratio = 0.8, CI: 0.6–1.1; p = 0.3). The incidence of proximal DVTs was 4% and 3%, respectively. No major bleeding occurred.Interpretation We found no significant difference in the incidence of DVT between the 2 treatment groups and our results do not support prolonged thromboprophylaxis. The overall incidence of DVT was high, reflecting the potential risk of PE and post-thrombotic syndrome after ankle fracture surgery. Most of the DVTs were asymptomatic, however, and were located in distal veins.

Clinical Syndromes and Clinical Outcome in Patients With Pulmonary Embolism: Findings From the RIETE Registry

<h3>Introduction</h3> The influence of the clinical syndromes of pulmonary embolism (PE) on clinical outcome has not been evaluated. <h3>Patients and methods</h3> The Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) is an ongoing registry of consecutive patients with acute venous thromboembolism. In this study, all enrolled patients with acute PE without preexisting cardiac or pulmonary disease were classified into three clinical syndromes: pulmonary infarction, isolated dyspnea, or circulatory collapse. Their clinical characteristics, laboratory findings, and 3-month outcomes were compared. <h3>Results</h3> As of January 2005, 4,145 patients with acute, symptomatic, objectively confirmed PE have been enrolled in RIETE. Of them, 3,391 patients (82%) had no chronic lung disease or heart failure: 1,709 patients (50%) had pulmonary infarction, 1,083 patients (32%) had isolated dyspnea, and 599 patients (18%) had circulatory collapse. Overall, 149 patients (4.4%) died during the first 15 days of therapy: 2.5% with pulmonary infarction, 6.2% with isolated dyspnea (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.7 to 3.8), and 6.5% with circulatory collapse (OR, 2.7; 95% CI, 1.7 to 4.2). From days 16 to 90, 31 patients had recurrent PE; 5 of 14 patients (36%) with pulmonary infarction died of their new PE, compared with 5 of 10 patients (50%) with isolated dyspnea, and all 7 patients (100%) with circulatory collapse. <h3>Conclusions</h3> PE patients with pulmonary infarction (50% of the whole series) had a significantly lower mortality rate both during initial therapy and after discharge.

Massive pulmonary embolism

Conclusion: Mortality of pulmonary embolism in patients with massive pulmonary embolism (PE) is not reduced by thrombolysis or embolectomy. There does appear to be reduced mortality in patients with massive PE who have placement of inferior vena cava filters. Summary: The International Cooperative Pulmonary Embolism Registry (ICOPER) enrolled 2454 consecutive patients with acute PE from January 1995 through November 1996. Fifty-two institutions in 7 countries were represented. There were 2392 patients with acute PE and known systolic blood pressure at presentation. Massive PE was defined as a systolic arterial pressure <90 mm Hg at presentation. Massive PE was present in 108 patients (4.5%), and 2284 patients (95.5%) had nonmassive PE. Sixteen patients with massive PE and 29 patients with nonmassive PE had the diagnosis of PE at autopsy (P < .01). For patients with massive PE, the 90-day mortality rate was 52.4% (95% confidence interval [CI], 43.3% to 62.1%). For patients with nonmassive PE, the 90-day mortality rate was 14.7% (95% CI, 13.3% to 16.2%). Within 90 days, recurrent PE occurred in 12.6% of patients with massive PE and in 7.6% with nonmassive PE (P < .001). In patients with massive PE, thrombolysis was performed in 33 patients, catheter embolectomy in one, and surgical embolectomy in three, for an overall active intervention rate for massive PE of 32%. These treatments were withheld in 68% (n = 73). The 90-day mortality rate was not reduced with thrombolytic therapy: thrombolysis, 46.6% (95% CI, 31.1 to 64.8%) vs no thrombolysis, 55.1% (95% CI, 44.3% to 66.7%; hazard ratio 0.79; 95% CI, 0.44 to 1.43). The incidence of recurrent PE at 90 days was 12% in patients with and without thrombolytic therapy (P = 0.99). Eleven patients received an inferior vena cava filter. None of these patients had recurrent PE within 90 days, and 10 (90.9%) survived at least 90 days. Inferior vena cava filters were associated with a decreased 90-day mortality (hazard ratio, 0.12; 95% CI, 0.02 to 0.85). Comment: It is probably wrong to conclude from these data that thrombolytic therapy cannot reduce mortality in patients with massive pulmonary embolism syndrome. ICOPER is a registry. Patients receiving thrombolytic therapy may have been the worst among the worst. The apparent significant reduction in mortality associated with inferior vena cava filters deserves further investigation, but it may also reflect those patients who are actually well enough to receive a filter. Clearly, improved and more standardized treatment of massive PE syndrome is needed.

Acute pulmonary embolism: An update on diagnosis and management

Pulmonary embolism (PE) is a common problem. Given the significant overlap of symptoms and si0gns between the presentation of PE and acute coronary syndromes, it becomes clear that cardiologists must be familiar with the diagnosis and treatment of PE. The critical issue is always to consider PE in the diagnosis of chest pain. It is then important to determine the likelihood of the diagnosis. For patients at moderate-to-high risk, helical CT provides a rapid and noninvasive diagnostic tool. Several other imaging studies are also available including ventilation/perfusion (V/Q) scan, magnetic resonance imaging, and pulmonary arteriography. Echocardiography can also provide valuable prognostic information. Several biomarkers including the d-dimers, troponins, and natriuretic peptides may provide additional information. The cornerstone of treatment includes anticoagulation. For patients with massive or submassive PE, thrombolysis and embolectomy should be considered. Finally, both primary and secondary prevention are critical to the long-term health of the patient.

Clinical Suspicion of Fatal Pulmonary Embolism

BackgroundLess than one third of patients with fatal pulmonary embolism (PE) are identified prior to autopsy. ObjectiveTo determine whether the clinical syndromes of acute PE are effective at identifying patients who die of this condition. MethodSeven hundred seventy-eight autopsy reports at the Buffalo General Hospital from 1991 to 1996 inclusive were reviewed. Inpatient medical records of 67 patients who were identified as having PE as the primary or major cause of death then were analyzed. ResultsThirty patients (45% [95% confidence interval, 33 to 57%]) had received a diagnosis of PE prior to death, which was marginally higher than the number previously reported (p < 0.05). The diagnosis of PE was significantly lower (13%; p < 0.01) in patients with COPD or coronary artery disease (33%; p < 0.01). In contrast to the prospective investigation of PE diagnosis data, only a minority of patients (6%) presented with pleuritic pain or hemoptysis, while a significantly larger proportion (24%; p < 0.01) of our patients experienced circulatory collapse. Only 55% were identified as having PE from the following clinical syndromes of PE: isolated dyspnea; pleuritic pain and/or hemoptysis; and circulatory collapse. Among the 30 patients suspected of having PE, only 14 (47%) received IV heparin in therapeutic doses, despite clinical suspicion. ConclusionOur results show a modest increase in the correct antemortem diagnosis of fatal PE. The current clinical syndromes used as markers for suspecting PE are not sufficient to detect patients who ultimately die of PE. Physicians should maintain a higher index of suspicion since fatal PE does not always present as one of the three clinical syndromes of PE. Once PE is suspected, heparin therapy should be started early.

Clinical Characteristics of Patients With Acute Pulmonary Embolism Stratified According to Their Presenting Syndromes

The purpose of this investigation is to determine the characteristics of the history, physical examination, chest radiograph, and ECG, and the ventilation/perfusion (V/Q) lung scan probability in patients with pulmonary embolism (PE) stratified according to their presenting syndrome. In considering a possible diagnosis of acute PE, it is helpful to consider the patient in terms of the presenting syndrome (pulmonary infarction, isolated dyspnea, or circulatory collapse). In assessing the possibility of acute PE, it would be more useful to know the detailed characteristics of the particular syndrome rather than the clinical characteristics of all patients with PE. Patients described in this investigation participated in the national collaborative trial of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). All had PE diagnosed by pulmonary angiography. None had prior cardiopulmonary disease. All examinations and laboratory tests were obtained within 24 h of the pulmonary angiogram and most were within 12 h of the pulmonary angiogram. Among patients with the pulmonary infarction syndrome, 14 of 119 (12%) had neither dyspnea nor tachypnea. Some patients with circulatory collapse did not have dyspnea, tachypnea, or pleuritic pain. A normal ECG was more prevalent among patients with pulmonary infarction syndrome, 45 of 97 (46%), than among patients with isolated dyspnea syndrome, 2 of 21 (10%) (p<0.01). A PaO2 >80 mm Hg was also more prevalent in patients with the pulmonary infarction syndrome, 27 of 99 (27%), than in patients with the isolated dyspnea syndrome, 2 of 19 (11%). A high-probability V/Q lung scan was less prevalent among the pulmonary infarction group, 38 of 119 (32%), than the isolated dyspnea group, 20 of 31 (65%) (p<0.001). Many of the findings in the various syndromes of PE can be understood in terms of the severity of PE as it increases from mild with the pulmonary infarction syndrome to moderate with the isolated dyspnea syndrome to severe with circulatory collapse. The prevalence of various clinical and laboratory characteristics of patients with the syndrome of pulmonary infarction, isolated dyspnea, or circulatory collapse may give clues to the diagnosis or suggest characteristics that may reduce the likelihood of inadvertently discarding the diagnosis of PE.