Pulmonary Thromboembolism

PULMONARY
THROMBOEMBOLISM
Respiratory consequences of PE
• The annual incidence of deep vein thrombosis

(DVT) and PE is estimated at 0.5-1 per 1000 in
the Western world.
• DVT and PE are both part of one entity: venous
thromboembolism (VTE).
• Both acquired and inherited risk factors have
been identified
Guidelines on diagnosis and management of acute pulmonary embolism, European Heart Journal, 2000
Risk factors for venous thromboembolism
Haemodynamic consequences of PE
Respiratory consequences of PE
Respiratory
consequences
of PE
Diagnosis of PE
• PE has a wide range of clinical presentation.
• Clinical evaluation is accurate to discriminate a subgroup
of patients with a low likelihood of PE.
• First line diagnostic tests, such as ECG, chest X-ray and
blood-gas analysis are indicated to assess clinical
probability of PE.
• Clinical probability may be estimated empirically or
explicitly by a prediction rule.
• Patients with a low clinical probability of PE, no lower limb
deep vein thrombosis and a nondiagnostic lung scan have
a very low risk of PE.
Diagnosis of PE
• Approximately 25% of patients with suspected PE will

have the diagnosis denyed by a normal perfusion lung
scan and anticoagulants may be safely deny.
• Around 25% of patients with suspected PE will have a
high probability lung scan and anticoagulant therapy may
be instituted.
• The remaining patients will require further diagnostic tests
as part of a wider diagnostic strategy.
Diagnosis of PE
• Pulmonary angiography is the reference method

• It is safe to withhold anticoagulant therapy in patients with
suspected PE and normal angiogram.
• Indirect signs of PE on angiography have not been
validated.
Diagnosis of PE
• Pulmonary angiography is the reference method

• It is safe to withhold anticoagulant therapy in patients with
suspected PE and normal angiogram.
• Indirect signs of PE on angiography have not been
validated.
• Spiral CT is more accurate in the demonstration of central
or lobar PE than segmental PE.
• A normal CT does not rule out isolated subsegmental PE.
• The safety of withholding anticoagulant therapy in patients
with a normal CT angiogram needs further confirmation.
Diagnosis of PE
• Echocardiography is useful in patients with suspected
massive PE.
• Whether echocardiography may identify patients who
could benefit from thrombolytic therapy in the absence of
systemic hypotension or shock
• Ultrasonography shows a proximal DVT in 50% of
patients with proven PE.
• A normal ultrasonography exam of the leg veins does not
rule out PE.
• Serial leg testing may replace angiography inpatients with
non-diagnostic lung scan findings.
Diagnosis of PE
• A normal D-dimer level by an ELISA assay may safely
exclude PE
• Traditional latex and whole agglutination tests have a low
sensitivity for PE and should not be used to rule out PE.
• D-dimer is most useful in emergency ward patients.
• In elderly or inpatients, D-dimer retains a high negative
predictive value
Proposed diagnostic
algorithm for non-massive
suspected pulmonary
embolism in emergency
room
Guidelines on diagnosis and management of

acute pulmonary embolism, European Heart
Journal, 2000
PE treatment
• Dobutamine and dopamine may be used in patients with

PE, low cardiac index and normal blood pressure.
• Vasopressive drugs may be used in hypotensive patients
with PE.
• Monitored oxygen therapy is beneficial in patients with PE
and hypoxaemia.
• The usefulness of fluid challenge is controversial and
should not exceed 500 ml.
Contraindication to fibrinolytic therapy in
patients with massive PE
PE treatment
• Thrombolytic therapy is indicated in patients with massive

PE, as shown by shock and/or hypotension.
• Most contraindications for thrombolytic therapy in massive
PE are relative.
• Thrombolytic therapy should be based on objective
diagnostic tests.
• The use of thrombolytic therapy in patients with sub-
massive PE (RV hypokinesia) is controversial.
• Thrombolytic therapy is not indicated in patients without
right ventricular overload.
PE treatment
• Thrombolytic therapy is indicated in patients with massive

PE, as shown by shock and/or hypotension.
• Most contraindications for thrombolytic therapy in massive
PE are relative.
• Thrombolytic therapy should be based on objective
diagnostic tests.
• The use of thrombolytic therapy in patients with sub-
massive PE (RV hypokinesia) is controversial.
• Thrombolytic therapy is not indicated in patients without
right ventricular overload.
PE treatment
• IVC filters are indicated to prevent PE in patients with

either absolute anticoagulation contraindications or
patients who suffer from recurrent VTE despite adequate
anticoagulant treatment.
• IVC filters are probably indicated after surgical
embolectomy.
• Retrievable IVC filters require further study to validate
their use.
Antiplatelet Agents
PE treatment
• IVC filters are indicated to prevent PE in patients with

either absolute anticoagulation contraindications or
patients who suffer from recurrent VTE despite adequate
anticoagulant treatment.
• IVC filters are probably indicated after surgical
embolectomy.
• Retrievable IVC filters require further study to validate
their use.
The Task Force on the Use of Antiplatelet Agents in Patients with Atherosclerotic
Cardiovascular Disease, European Society of Cardiology, 2004
Main features of aspirin, clopidogrel
and GPIIb/IIIa antagonists
The absolute risk of vascular
complications
Recommendations on the use of
antiplatelet agents
antiplatelet agents
antiplatelet agents
• aspirin is used appropriately widely among those who are known to

benefit.
• many patients who may benefit do not receive aspirin, and
considerable efforts are needed to remedy this.
• In those high-risk patients who do already take aspirin, however, the
largest gains are likely to result from adding a second anti-thrombotic
agent-either an antiplatelet or an anticoagulant, depending on
circumstances.
• replacing one anti-thrombotic drug with another of the same (or
similar) type offers little scope for major improvements in
cardiovascular prevention, since the true difference between such
drugs is likely to be modest.

Pulmonary Thromboembolism

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PULMONARY

• The annual incidence of deep vein thrombosis

• Approximately 25% of patients with suspected PE will

• Pulmonary angiography is the reference method

• Pulmonary angiography is the reference method

Guidelines on diagnosis and management of

• Dobutamine and dopamine may be used in patients with

• Thrombolytic therapy is indicated in patients with massive

• Thrombolytic therapy is indicated in patients with massive

• IVC filters are indicated to prevent PE in patients with

• IVC filters are indicated to prevent PE in patients with

• aspirin is used appropriately widely among those who are known to

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