The Diagnosis and Treatment of Acute Pulmonary Embolism

Alexander Schellhaaß

Andreas Walther

Stavros Konstantinides

Bernd Böttiger

^{Klinik für Anästhesiologie, Universitätsklinikum Heidelberg}

^{Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Katharinenhospital}

^{Department of Cardiology, University General Hospital Alexandroupolis, Griechenland}

^{Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln}

*Klinik für Anaesthesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany

Received 2009 Jul 27; Accepted 2009 Nov 16.

Abstract

Background

Pulmonary embolism (PE) is a cardiovascular emergency with high morbidity and mortality.

Methods

Review of relevant literature retrieved by a selective Medline search, including current guidelines.

Results

Hemodynamically unstable patients are considered to have high-risk PE, whereas hemodynamically stable patients are considered to have non-high-risk PE. After classification into one of these two risk groups, patients undergo further diagnostic evaluation for PE according to the appropriate risk-adapted algorithm. Patients who are in cardiogenic shock or have persistent arterial hypotension (high-risk PE) should undergo multidetector computed tomography (MDCT) or echocardiography at once, so that a PE, if present, can be treated immediately by thrombolysis. For hemodynamically stable patients with non-high-risk PE the proper diagnostic strategy is determined by the clinical probability of PE, which can be calculated with the aid of validated scoring systems and is based on both MDCT and D-dimer levels. For further risk stratification in hemodynamically stable patients, tests are performed to detect right ventricular dysfunction or myocardial injury, either of which indicates intermediate-risk PE. In addition to specific therapy, patients with high-risk PE, patients at high risk for hemorrhage and these with severe renal insufficiency should be anticoagulated with unfractionated heparin. All other patients should be treated with low-molecular-weight heparin or fondaparinux. Thereafter, long-term oral anticoagulation with vitamin K antagonists is recommended.

Conclusion

Modern algorithms have considerably simplified the diagnosis and treatment of acute PE. It would be desirable for these algorithms to be rapidly implemented in routine practice, because speedy diagnosis and immediate treatment can lower the morbidity and mortality associated with PE.

Abstract

Despite many medical advances, acute pulmonary embolism (PE) remains a cardiovascular emergency with high morbidity and mortality. With clinically suspected PE, rapid and targeted treatment is essential because speedy diagnosis and immediate therapy can lower the morbidity and mortality associated with PE (1). However, the non-specific clinical presentation and the variety of suggested diagnostic algorithms, some of which are complex, can impede speedy and certain diagnosis (2). In light of this, the authors carried out a selective Medline literature review for this review article, taking into consideration a recent comprehensive review of the guidelines issued by the European Society for Cardiology (ESC) (3), the official comments from the German Cardiac Society (4) and the German interdisciplinary S2 guidelines (5). The authors would like to inform the reader of clear diagnostic procedures—dependent on the hemodynamic status of the patient—which have been simplified compared to previous review articles. The authors would also like to suggest risk-adapted, evidence-based therapeutic strategies that conform to these guidelines.

Acknowledgments

Translated from the original German by language & letters.

Acknowledgments

Footnotes

Conflict of interest statement

Prof. Böttiger is Chairman of the European Resuscitation Council (ERC). The remaining authors declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.

Footnotes

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