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Int J Angiol 2019; 28(02): 100-111
DOI: 10.1055/s-0039-1692636
Invited Article: Pulmonary Arterial Hypertension
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Acute Pulmonary Embolism: Contemporary Approach to Diagnosis, Risk-Stratification, and Management

Tahir Tak
1   Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
,
Swetha Karturi
2   Department of Hospital Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
,
Umesh Sharma
2   Department of Hospital Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
,
Lee Eckstein
3   Department of Imaging Services, Mayo Clinic Health System, La Crosse, Wisconsin
,
Joseph T. Poterucha
4   Division of Critical Care Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
,
Yader Sandoval
1   Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Publikationsdatum:
05. Juli 2019 (online)

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Abstract

Pulmonary embolism (PE) affects over 300,000 individuals each year in the United States and is associated with substantial morbidity and mortality. Improvements in the diagnostic performance and availability of computed tomographic pulmonary angiography and D-dimer testing have facilitated the evaluation of patients with suspected PE. High clinical suspicion is required in those with risk factors and/or those that manifest signs or symptoms of venous thromboembolic disease, with validated clinical risk scores such as the Wells and modified Wells score or the PE rule-out criteria helpful in estimating the likelihood for PE. For those with confirmed PE, patients should be categorized and triaged according to the presence or absence of shock or hypotension. Normotensive patients can be further risk-stratified using validated prognostic risk scores, as well as by using imaging and cardiac biomarkers, with those having either signs of right ventricular dysfunction on imaging studies and/or abnormal cardiac biomarkers categorized as being at intermediate-risk and requiring close monitoring and hospital admission. Early discharge and/or home therapy are possible in those that do not manifest any high-risk features. The initial treatment for most patients that are stable consists of anticoagulation, with advanced therapies such as thrombolysis, catheter-based therapies, or surgical embolectomy deferred for those at high risk. Given the heterogeneous presentations of PE and various management strategies available, the development of multidisciplinary PE response teams has emerged to help facilitate decision-making in these patients.

Keywords

pulmonary embolism - pulmonary hypertension - deep venous thrombosis - dyspnea - anticoagulation - thrombolytic - echocardiography - right heart strain - tumor emboli - vena cava filters