I subscribe to about 15 journals in internal medicine, cardiology, haematology, and pulmonary disease. I use a “tear and file” system to track relevant articles. To ensure that I have not missed important articles in other journals, I check the venous thrombosis articles weekly on the AMEDEO web page. For selection in this seminar, I searched MEDLINE (1993–2003) with the search terms “pulmonary embolism” and “clinical” and “OVID full text”. I chose mostly recent articles published in
SeminarPulmonary embolism
Section snippets
Epidemiology
Although PE and deep venous thrombosis (DVT) can be notoriously difficult to diagnose,1 hospital admission rates for venous thromboembolism (VTE) increased in the UK in the 1990s.2 Despite challenges in detection of VTE, cohort studies show consistency in incidence estimates among western populations. In the Brest district of France, the annual incidence was 1·83 per 1000.3 In Olmsted County, MN, USA, the most recent annual incidence estimate was 1·22 per 1000 among adults.4 In the Longitudinal
Risk factors
Understanding of risk factors for VTE12, 13 will increase the likelihood that DVT and PE can be diagnosed and prevented. These factors include environmental, natural, and hormonal influences (panel 1).
Pathophysiology
Venous stasis and endothelial damage predispose to VTE, especially among patients with underlying hyper-coagulable states. Those with previous PE or DVT are particularly susceptible to recurrences. Most cases of PE result from thrombi that originate in the pelvic region or deep veins of the leg. When venous thrombi become dislodged from their sites of formation, they move through the venous system to the pulmonary arterial circulation. Extremely large emboli can lodge at the bifurcation of the
Clinical suspicion
Diagnosis of PE poses a major challenge because classic symptoms and signs are not present in many cases. PE can present with subtle findings in young, previously healthy patients who have excellent cardiac reserve. With increasing age, PE tends to masquerade as other illnesses such as acute coronary syndrome or exacerbation of chronic obstructive pulmonary disease. Accurate diagnosis of PE is particularly difficult when patients present with two concurrent illnesses, such as obvious pneumonia
Imaging studies
The traditional imaging test for suspected PE has been the ventilation/ perfusion lung scan. High-probability lung scans and normal lung scans are well validated with paired contrast pulmonary angiograms for diagnosis and exclusion of PE, respectively.57 The main difficulty with lung scanning is that most scans are of intermediate or indeterminate probability. These non-diagnostic scans can cause consternation among clinicians who have either to undertake additional imaging tests or to decide
Risk stratification
Clinically, PE ranges from massive thromboembolism with cardiogenic shock to asymptomatic, anatomically small emboli without haemodynamic, respiratory, or other adverse physiological consequences. The key to appropriate therapy is risk stratification. Low-risk patients have an excellent prognosis with anticoagulation alone. High-risk patients might benefit from thrombolysis or embolectomy in addition to intensive anticoagulation. The Geneva prognostic index identified six factors that predict
Long-term recurrent PE
After an initial VTE, patients are at risk of recurrence for at least 10 years.102 Patients who develop PE after an operation have the lowest recurrence rates.103 After withdrawal of anticoagulants, a normal D-dimer concentration has a high negative predictive value for recurrent thromboembolism.104
In-hospital primary prevention
Vigilant general physicians can improve outcomes by prescribing intensive and effective prophylaxis described in comprehensive consensus guidelines.105, 106 Computer-generated prompts can remind
Search strategy and selection criteria
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Assessment of cardiac stress from massive pulmonary embolism with 12-lead ECG
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Arterial blood gas analysis in the assessment of suspected acute pulmonary embolism
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Alveolar-arterial oxygen gradient in the assessment of acute pulmonary embolism
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Role of D-dimers in diagnosis of venous thromboembolism
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Normal D-dimer levels in emergency department patients suspected of acute pulmonary embolism
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Non-invasive diagnosis of venous thromboembolism in outpatients
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Comparison of contrast-enhanced magnetic resonance angiography and conventional pulmonary angiography for the diagnosis of pulmonary embolism: a prospective study
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Value of transthoracic echocardiography in the diagnosis of pulmonary embolism: results of a prospective study in unselected patients
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Clinical validity of a normal pulmonary angiogram in patients with suspected pulmonary embolism: a critical review
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Overview of prospective investigation of pulmonary embolism diagnosis II
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Oral anticoagulation self-management and management by a specialist anticoagulation clinic: a randomised cross-over comparison
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Thrombolytic therapy of pulmonary embolism: a meta-analysis
J Am Coll Cardiol
Thrombolysis in submassive pulmonary embolism? No
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Thrombolysis or heparin therapy in massive pulmonary embolism with right ventricular dilation: results from a 128-patient monocenter registry
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Incidence of venous thromboembolism: a community-based study in Western France
Thromb Haemost
Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study
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Cardiovascular risk factors and venous thromboembolism incidence: the longitudinal investigation of thromboembolism etiology
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Predictors of survival after deep vein thrombosis and pulmonary embolism: a population-based, cohort study
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Clinical characteristics of acute pulmonary thromboembolism in Japan: results of a multicenter registry in the Japanese Society of Pulmonary Embolism Research
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The clinical course of patients with suspected pulmonary embolism
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Risk of fatal pulmonary embolism in patients with treated venous thromboembolism
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An epidemiologic study of risk factors for deep vein thrombosis in medical outpatients: the Sirius study
Arch Intern Med
Risk factors for venous thromboembolism
Circulation
Severe pulmonary embolism associated with air travel
N Engl J Med
A prospective study of risk factors for pulmonary embolism in women
JAMA
Oral contraceptives and the risk of venous thrombosis
N Engl J Med
Increased frequency of genetic thrombophilia in women with complications of pregnancy
N Engl J Med
Inherited thrombophilia and first venous thromboembolism during pregnancy and puerperium
Thromb Haemost
Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial
JAMA
Postmenopausal hormone replacement therapy: scientific review
JAMA
The effect of raloxifene on risk of breast cancer in postmenopausal women: results from the MORE randomized trial
JAMA
First results from the International Breast Cancer Intervention Study (IBIS-I): a randomised prevention trial
Lancet
Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer
N Engl J Med
Incidence of cancer after prophylaxis with warfarin against recurrent venous thromboembolism: Duration of Anticoagulation Trial
N Engl J Med
Prognosis of cancers associated with venous thromboembolism
N Engl J Med
Deep-vein thrombosis and the incidence of subsequent symptomatic cancer
N Engl J Med
Genetic susceptibility to venous thrombosis
N Engl J Med
Factor V Leiden mutation and the risks for thromboembolic disease: a clinical perspective
Ann Intern Med
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