Elsevier

The Lancet

Volume 363, Issue 9417, 17 April 2004, Pages 1295-1305
The Lancet

Seminar
Pulmonary embolism

https://doi.org/10.1016/S0140-6736(04)16004-2Get rights and content

Summary

Pulmonary embolism (PE) is a common illness that can cause death and disability. It is difficult to detect because patients present with a wide array of symptoms and signs. The clinical setting can raise suspicion, and certain inherited and acquired risk factors predispose susceptible individuals. D-dimer concentration in blood is the best laboratory screening test, and chest CT has become the most widespread imaging test. Treatment requires rapid and accurate risk stratification before haemodynamic decompensation and the development of cardiogenic shock. Anticoagulation is the foundation of therapy. Right-ventricular dysfunction on echocardiography and higher than normal concentrations of troponin identify high-risk patients who might need escalation of therapy with thrombolysis or embolectomy even if the blood pressure is normal on presentation. When patients are admitted to medical wards or when patients undergo surgery, their physicians should prescribe prophylactic measures to prevent PE. After hospital discharge, prophylaxis should continue for about a month for patients at high risk of thromboembolism.

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

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

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