PULMONARY EMBOLISM

PRESENTER :GEORVIN MARCO

SUPERVISOR:DR.RAMADHAN.
• Pulmonary embolism (PE) occurs when there is a disruption to the flow of
blood in the pulmonary artery or its branches by a thrombus that originated
somewhere else.

• In deep vein thrombosis (DVT), a thrombus develops within the deep veins,
most commonly in the lower extremities.

• PE usually occurs when a part of this thrombus breaks off and enters the
pulmonary circulation. Very rarely, PE can occur from the embolization of
other materials into the pulmonary circulation such as air, fat, or tumor cells.

• The spectrum of PE and DVT combined is referred to as venous

thromboembolism (VTE).
 aetiology
• Most PE originate as lower extremity DVTs. Hence, risk factors
for (PE) are the same as risk factors for DVT.
• Virchow's triad of hypercoagulability, venous stasis, and
endothelial injury provides an understanding of these risk
factors.
• Risk factors can be classified as genetic and acquired.
• Genetic risk factors include thrombophilia such as factor V
Leiden mutation, prothrombin gene mutation, protein C
deficiency, protein S deficiency, hyperhomocysteinemia.
• among others. Acquired risk factors include immobilization for
prolonged periods (bed rest greater than three days, anyone
traveling greater than 4 h
• recent orthopedic surgery, malignancy, indwelling venous catheter,
obesity, pregnancy, cigarette smoking, oral contraceptive pill use.
• Other predisposing factors for VTE include,Fracture of lower limb
Hospitalization for heart failure or atrial fibrillation/flutter within the
previous three months Hip or knee replacement Major trauma

• History of previous venous thromboembolism ,Central venous

lines,Chemotherapy ,Congestive heart failure or respiratory
failure,Hormone replacement therapy ,Oral contraceptive
therapy,Postpartum period,Infection (specifically pneumonia, urinary
tract infection, and HIV),Cancer (highest risk in metastatic
disease),Thrombophilia,Bed rest greater than three
days,Obesity,Pregnancy.
• Cancer carries a high risk for thrombus formation
and hence, PE. Pancreatic cancer, hematological
malignancies, lung cancer, gastric cancer, and brain
cancer carry the highest risk for VTE.
• Infection anywhere in the body is a common trigger
for VTE.
• Myocardial infarction and congestive heart
failure(CHF) increase the risk of PE. Also, patients
with VTE were found to have an increased risk of
subsequent stroke and myocardial infarction.
 Types of Pulmonary Embolism

• It is extremely crucial to divide PE based on the presence or absence of

hemodynamic stability.
• Hemodynamically unstable PE (previously called massive or high-risk PE) is
PE which results in hypotension (as defined by systolic blood pressure
(SBP) less than 90 mmHg or a drop in SBP of 40 mm Hg or more from
baseline or hypotension that requires vasopressors or inotropes), the old
term "massive" PE does not describe the size of the PE but describes its
hemodynamic effect. Patients with hemodynamically unstable PE are more
likely to die from obstructive shock (i.e., severe right ventricular failure).
• Hemodynamically stable PE is a spectrum ranging from small, mildly
symptomatic or asymptomatic PE (low-risk PE or small PE) to PEs, which
cause mild hypotension that stabilizes in response to fluid therapy, or
those who present with right ventricle dysfunction (submassive or
intermediate-risk PE), but is hemodynamically stable.
 Epidemiology

• The incidence of pulmonary embolism (PE) ranges from 39 to 115 per 100 000
population annually; for DVT, the incidence ranges from 53 to 162 per 100,000
people
• After coronary artery disease and stroke, acute pulmonary embolism is the
third most common type of cardiovascular disease.
• The incidence of PE is noted to be more in males as compared to that in
females.
• Overall, PE related mortality is high, and in the United States, PE causes
100,000 deaths annually.
• However, the mortality rates attributable to PE can be challenging to estimate
accurately because many patients with sudden cardiac death are thought to
have had a thromboembolic event like PE. It is important to note that the case-
fatality rates of PE have been decreasing; this might be from the improvement
in diagnostic modalities and initiation of early intervention and therapies.
• Pulmonary embolism occurs when clots break off and embolize into the pulmonary
circulation.
• Pulmonary emboli are typically multiple, with the lower lobes being involved more
frequently than the upper, and bilateral lung involvement being more common.[13]
• Large emboli tend to obstruct the main pulmonary artery, causing saddle embolus
with deleterious cardiovascular consequences. In contrast, smaller sized emboli block
the peripheral arteries and can lead to pulmonary infarction, manifested by intra-
alveolar hemorrhage. Pulmonary infarction occurs in about 10% of patients.
• PE leads to impaired gas exchange due to obstruction of the pulmonary vascular bed
leading to a mismatch in the ventilation to perfusion ratio because alveolar
ventilation remains the same, but pulmonary capillary blood flow decreases,
effectively leading to dead space ventilation and hypoxemia.
• Also, mediators, such as serotonin, are released, which cause vasospasm and further
decreased pulmonary flow in unaffected areas of the lung. Local accumulation of
inflammatory mediators alters lung surfactant and stimulates respiratory drive
resulting in hypocapnia and respiratory alkalosis.[14]
• In PE, pulmonary vascular resistance (PVR) increases due to the mechanical
obstruction of the vascular bed with thrombus and hypoxic vasoconstriction.
Pulmonary artery pressure (PAP) increases if thromboemboli occludes greater than
30% to 50% of the total cross-sectional area of the pulmonary arterial bed.
• Increased PVR increases the right ventricular afterload, which impedes right
ventricular outflow, which, in turn, causes right ventricular dilation and flattening
or bowing of the interventricular septum. The desynchronization of the ventricles
may be increased by the development of the right bundle branch block. The
decreased RV outflow and concomitant RV dilation reduce left ventricular filling,
thereby compromising cardiac output.[15] As a result, LV filling is reduced in early
diastole, and this leads to a reduction in the cardiac output (CO), and cause
systemic hypotension and hemodynamic instability. Right ventricle (RV) failure due
to acute pressure overload is the primary cause of death in severe PE. Given the
above pathophysiological considerations, clinical symptoms, and signs of overt RV
failure and hemodynamic instability, are indicative of a high risk of early (in-
hospital or 30 day) mortality.
• History and Physical
• A timely diagnosis of a pulmonary embolism (PE) is crucial because of the high associated mortality
and morbidity, which may be prevented with early treatment. It is important to note that 30% of
untreated patients with pulmonary embolism die, while only 8% die after timely therapy.[16][17]
Unfortunately, the diagnosis of PE can be difficult due to the wide variety of nonspecific clinical signs
and symptoms in patients with acute PE.
• The most common symptoms of PE include the following: dyspnea, pleuritic chest pain, cough,
hemoptysis, presyncope, or syncope. Dyspnea may be acute and severe in central PE, whereas it is
often mild and transient in small peripheral PE. In patients with preexisting heart failure or pulmonary
disease, worsening dyspnea may be the only symptom. Chest pain is a frequent symptom and is
usually caused by pleural irritation due to distal emboli causing pulmonary infarction.[18] In central
PE, chest pain may be from underlying right ventricular (RV) ischemia and needs to be differentiated
from an acute coronary syndrome or aortic dissection.
• Less common presentations include arrhythmias (e.g., atrial fibrillation), syncope, and hemodynamic
collapse.[19] Hemodynamic instability is a rare but essential form of clinical presentation, as it
indicates central or extensive PE with severely reduced hemodynamic reserve. Syncope may occur
and may be associated with a higher prevalence of hemodynamic instability and RV dysfunction.[20] It
is essential to recognize that patients with large PE may, at times, be asymptomatic or have mild
symptoms. Many times, PE may be asymptomatic or discovered incidentally during diagnostic workup
for another disease
• Apart from symptoms of PE, it is crucial to look for the risk factors for venous
thromboembolism (VTE) to determine the clinical probability of a PE.
• On examination, patients with PE might have tachypnea and tachycardia, which are
common but nonspecific findings. Other examination findings include calf swelling,
tenderness, erythema, palpable cords, pedal edema, rales, decreased breath sounds,
signs of pulmonary hypertension such as elevated neck veins, loud P2 component of
second heart sound, a right-sided gallop, and a right ventricular parasternal lift might
be present on examination.
• PE is a well-recognized cause of sudden cardiac arrest (8%).[21] A massive PE leads to
an acute right ventricular failure, which presents as jugular venous distension,
parasternal lift, third heart sound, cyanosis, and shock. If a patient with PE who has
tachycardia on presentation develops sudden bradycardia or develops a new broad
complex tachycardia (with right bundle branch block), providers should look for signs
of right ventricular strain and possible impending shock. PE should be suspected in
anyone who has hypotension with jugular venous distension wherein acute
myocardial infarction, pericardial tamponade, or tension pneumothorax has been
ruled out.[22]
• Diagnostic Workup
• Arterial Blood Gas (ABG) Analysis
• Unexplained hypoxemia with a normal chest radiograph should raise the clinical suspicion for
pulmonary embolism (PE). Widened alveolar-arterial gradient for oxygen, respiratory alkalosis,
and hypocapnia are commonly seen findings on ABG, as a pathophysiological response to
pulmonary embolism. It is important to note that hypercapnia, respiratory, or lactic acidosis is
not common but can be present in patients with massive PE associated with obstructive shock
and respiratory arrest.
• Brain Natriuretic Peptide (BNP)
• Elevated BNP has limited diagnostic importance in patients suspected of having PE.[23] Right
ventricle pressure overload because of acute PE is associated with more myocardial stretch,
which then releases B-type natriuretic peptide (BNP) and N-terminal (NT)-proBNP. Thus, the
levels of natriuretic peptides in blood reflect the severity of RV dysfunction in acute PE.[24]
• Troponin
• Serum troponin I and T levels are beneficial prognostically but not diagnostically.[25][26] As
markers of right ventricular dysfunction, troponin levels are elevated in 30 to 50 percent of
patients with moderate to large PE and are linked to clinical deterioration and death after PE.
[27]
• D-dimer
• D-dimer levels are elevated in plasma whenever there is an acute thrombotic process in the body because of
the activation of coagulation and fibrinolysis pathways at the same time. D-dimer testing has high negative
predictive value; hence, a normal D-dimer level makes acute PE or DVT unlikely. But since the positive
predictive value of elevated D-dimer levels is low, D-dimer testing is not useful for confirmation of PE. As
many D-dimer assays are available, providers should become aware of the diagnostic performance of the
test used in their clinical setting. The quantitative enzyme-linked immunosorbent assay (ELISA) has a
diagnostic sensitivity of at least 95%. It can be used to exclude the diagnosis of PE in patients with either low
or intermediate pretest probability. A negative ELISA D-dimer, along with low clinical probability, can exclude
PE without further testing in approximately 30% of suspected patients.
• The specificity of D-dimer decreases steadily with age to approximately 10% in patients greater than 80
years of age. The use of age-adjusted cut-offs for patients older than 50 may improve the performance of D-
dimer testing in the elderly. In one study, the use of the age-adjusted cut-off instead of the standard D-dimer
cut-off of 500 ng/mL or more increased the number of patients in whom the possibility of PE could be ruled
out from 6.4% to 30%, without additional false-negative findings.[28]
• The formula is age (years) x 10 mcg/L for patients more than 50 years of age. Example: Patient age 75 = age-
adjusted d-dimer of 750 mcg/L.
• Electrocardiography (ECG)
• ECG abnormalities, in patients with suspected PE, are nonspecific.[29] The most common ECG findings in PE
are tachycardia and nonspecific ST-segment and T-wave changes, S1Q3T3 pattern, right ventricular strain,
and new incomplete right bundle branch block are uncommon.
• Chest Radiograph (CXR)
• In PE, CXR is usually normal or might show nonspecific abnormalities such as atelectasis or effusion. It helps to rule out alternative diagnoses in
patients presenting with acute dyspnea.
• Hampton's hump is a shallow, hump-shaped opacity on CXR in the periphery of the lung, with its base lying against the pleural surface and hump
towards the hilum (Figure 1). Westermark's sign is the sharp cut-off of pulmonary vessels with distal hypoperfusion in a segmental distribution
within the lung; both of these findings are rare but specific for acute PE.[30] 'Westermark sign' may be seen in up to 2% of the cases. This finding is
a result of a combination of dilation of the pulmonary artery proximal to the thrombus and the collapse of the distal vasculature (figure 2).

• Computed Tomographic Pulmonary Angiography (CTPA)

• Multidetector CTPA is the diagnostic modality of choice for patients with suspected PE. It allows appropriate visualization of the pulmonary
arteries down to the subsegmental level.[31] The PIOPED (Prospective Investigation On Pulmonary Embolism Diagnosis) II study showed a
sensitivity of 83% and a specificity of 96% for CTPA in PE diagnosis.[32] PIOPED II also highlighted the pretest clinical probability influence on the
predictive value of CTPA. A normal CTPA had a high negative predictive value for PE 96% and 89% in patients with a low or intermediate clinical
probability, respectively, but its negative predictive value was only 60% if the pretest probability was high. In contrary to this, the positive
predictive value of a positive CTPA was high (92% to 96%) in patients with an intermediate or high clinical probability, but much lower (58%) in
patients with a low pretest likelihood of PE.[32] Therefore, providers should consider further testing in case of discordance between clinical
judgment and the CTPA result.
• The present data suggest that a negative CTPA result is adequate for the exclusion of PE in patients who have a low or intermediate clinical
probability. Besides, it remains controversial whether patients with a negative CTPA and a high clinical probability should be further investigated.
• CTPA may be relatively contraindicated in moderate to severe iodinated contrast allergy or renal insufficiency (eGFR less than 30 mL/min per 1.73-
meter square). The risk of these contraindications must be measured against the clinical significance of performing the CTPA examination and the
availability of other imaging modalities (e.g., V/Q scan). If clinically feasible, CTPA should be postponed for premedication for a history of allergy or
intravenous hydration for renal insufficiency.
• CTPA can detect RV enlargement and other indicators of RV dysfunction. Enlarged RV has prognostic value, and it is supported by the results of a
prospective multicentre cohort study in 457 patients.[33] In that study, RV enlargement (RV/LV ratio ≥0.9) was a strong and independent predictor
of a severe in-hospital outcome, both in the overall population and in hemodynamically stable patients.
• Lung Scintigraphy
• The planar ventilation/perfusion scan (V/Q scan) is an established diagnostic test for suspected PE. V/Q scanning is mostly
performed for patients in whom CTPA is contraindicated or inconclusive, or when additional testing is needed. A normal
chest radiograph is usually required before V/Q scanning. Scans performed on patients with abnormal chest radiographs
are most likely to be false positives because the images do not appear normal or low probability of PE in such patients.
• For those with a normal chest radiograph, V/Q scanning remains the test of choice for the diagnosis of PE in pregnancy.
Other groups of patients include those who have a history of contrast medium-induced anaphylaxis and patients with
severe renal failure.[34]
• Planar lung scan results are frequently classified into three-tiers: normal scan (excluding PE), high-probability scan
(considered diagnostic of PE in most patients), and nondiagnostic scan.[34][35] Multiple studies have suggested that it is
safe to withhold anticoagulant therapy in patients with a normal perfusion scan.[36] An analysis from the PIOPED II study
advocated that a high-probability V/Q scan can confirm PE. However, the positive predictive value of a high-probability
V/Q scan is not enough to confirm the PE diagnosis in patients with a low clinical probability.[37] The high frequency of
nondiagnostic scans is a limitation because they indicate the necessity for further diagnostic testing.
• Pulmonary Angiography
• In pulmonary angiography, contrast is injected via a catheter introduced into the right heart under fluoroscopy, which was
the gold standard in the past for the diagnosis of PE. The diagnosis of acute PE is made on the evidence of a thrombus
either as amputation of a pulmonary arterial branch or filling defect.[38] With the widespread emergence of CTPA,
pulmonary angiography is infrequently used and reserved for rare circumstances for patients with a high clinical
probability of PE, in whom CTPA or V/Q scanning is nondiagnostic. Pulmonary angiography seems to be inferior to CTPA,
and its results are operator dependent and highly variable.[39] Therefore, catheter-based pulmonary angiography is
performed in patients who need therapeutic benefit since it helps with diagnosis as well as therapeutic interventions
aimed at clot lysis.
• Magnetic Resonance Angiography
• Magnetic resonance angiography (MRA) has been assessed for several years regarding suspected PE. However, the results of large-scale
studies show that this technique, although promising, is not recommended as a first-line test for the diagnosis of PE due to its low
sensitivity, low availability in most emergency settings, and the high proportion of inconclusive MRA scans.[40] But it may be an imaging
option for diagnosis of PE in patients in whom neither CTPA nor V/Q scan can be performed. Potential advantages include no exposure to
radiation. MR pulmonary angiography was studied prospectively in 371 adults with suspected PE. Among the 75 percent of patients who
had technically adequate images, MRPA alone showed a sensitivity and specificity of 78 percent and 99 percent, respectively.[40] Among
the 48 percent of patients with technically adequate images, MR pulmonary angiography and MR pulmonary venography have shown a
sensitivity and specificity of 92 percent and 96 percent, respectively.

• Echocardiography
• Transthoracic echocardiography can very rarely diagnose PE definitively when the thrombus is visualized in the proximal pulmonary
arteries. The diagnosis of PE on echocardiography is supported by the presence of clot in the right heart or new right heart strain,
especially in hemodynamically unstable patients with suspected PE wherein echocardiogram may be useful to establish a possible
diagnosis and justify the emergency use of thrombolytic therapy.
• There are significant considerations with using echocardiography to establish a diagnosis of PE. Given the peculiar shape of the RV, there is
no single echocardiographic parameter that gives quick and accurate information on RV size or function. That is why echocardiographic
criteria for the diagnosis of PE have varied between different studies. Because of the negative predictive value of 40% to 50%, a negative
result cannot exclude PE.[41][42] On the other hand, signs of RV overload or dysfunction may also be present without acute PE, and may
be due to coexisting cardiac or respiratory disease.[43]
• RV dilation is seen in 25% or more of patients with PE on echo and is useful for risk stratification of the disease.[44] More specific
echocardiography findings confer a high positive predictive value for PE, even in the presence of preexisting cardiorespiratory illness. This
includes, the combination of a pulmonary ejection acceleration time (measured in the RV outflow tract) less than 60 ms with a peak
systolic tricuspid valve gradient less than 60 mmHg ('60/60' sign), or McConnell sign (with depressed contractility of the RV free wall
compared to the RV apex), is suggestive of PE.[45]. An RV/LV diameter ratio 1.0 or more and tricuspid annular plane systolic excursion
(TAPSE) less than 16 mm are the findings for which an association with unfavorable prognosis has most frequently been reported.[46]
• Compression Ultrasonography (US)
• PE originates from a lower limb DVT in a majority of patients, and only rarely
from upper-limb DVT (mostly following venous catheterization). In one
study, DVT was found in 70% of patients with proven PE.[47] Compression
US has a sensitivity of more than 90% and a specificity of about 95% for
proximal symptomatic DVT.[48] A finding of proximal DVT in patients
suspected of having PE is considered sufficient to warrant anticoagulant
treatment without further testing.[49] It is important to note that, due to
the low sensitivity of compression ultrasonography, it is reserved for
patients in whom definitive imaging (e.g., CTPA, V/Q scanning) is
contraindicated or indeterminate.[50]
• Wells criteria and Geneva score are scoring systems most commonly used to
estimate the pretest probability of having a PE. This allows the classification
of patients with suspected PE into categories of clinical or pretest
probability, based on which the diagnostic tests are chosen and interpreted.
• The Revised Geneva Clinical Prediction Rule
• Items/Clinical decision rule points (Original version)(Simplified
version)
• Previous PE or DVT-3/1
• Heart rate75–94 beats per minute-3/1
• ≥95 beats per minute-5/2
• Surgery or fracture within the past month-2/1
• Hemoptysis-2/1
• Active cancer-2/1
• Unilateral lower-limb pain-3/1
• Pain on lower-limb deep palpation and unilateral edema-4/1
• Age >65 years-1/1
• Wells Criteria and Modified Wells Criteria
• Items/Scores
• Clinical symptoms of DVT-3.0
• Other diagnoses less likely than pulmonary embolism-3.0
• Heart rate >100 beats per min-1.5
• Immobilization for three or more days or surgery in the previous four weeks-1.5
• Previous history of DVT-PE1.5
• Hemoptysis-1.0
• Malignancy-1.0
• Probability/ Score
• Traditional Clinical Probability Assessment (Wells criteria)
• High/>6.0
• Moderate/2.0 to 6.0
• Low/<2.0
• Simplified Clinical Probability Assessment (Modified Wells Criteria)
• PE likely/>4.0
• PE unlikely/≤4.0
 The Pulmonary Embolism Rule-out Criteria
(PERC)
• Since symptoms of PE are very nonspecific, The Pulmonary Embolism Rule-out Criteria (PERC) was
developed for emergency department patients to select patients whose likelihood of having PE is so
low that diagnostic workup should not even be initiated.[51] They constitute variables significantly
associated with the absence of PE.
• The PERC rule has eight criteria:
• • Age <50 years
• • Heart rate <100 beats per minute
• • Oxyhemoglobin saturation ≥95 percent
• • No hemoptysis
• • No estrogen use
• • No prior DVT or PE
• • No unilateral leg swelling
• • No surgery/trauma requiring hospitalization within the preceding four weeks
• Patients having a low probability of PE who fulfill all eight criteria, the likelihood of PE is sufficiently low
that further testing is not indicated.
• PERC is only valid in clinical settings with a low prevalence of PE (<15 percent).[52] In hospital settings
with a higher prevalence of PE (>15 percent), the PERC-based approach has substantially weaker
predictive value.[53] Therefore, it should not be used in patients with an intermediate or high
suspicion for PE or for inpatients suspected as having PE.
• Patients having a low probability of PE who fulfill all eight criteria, the likelihood of PE is sufficiently low that further testing is not
indicated.
• PERC is only valid in clinical settings with a low prevalence of PE (<15 percent).[52] In hospital settings with a higher prevalence of
PE (>15 percent), the PERC-based approach has substantially weaker predictive value.[53] Therefore, it should not be used in
patients with an intermediate or high suspicion for PE or for inpatients suspected as having PE.
• Diagnostic Approach to Hemodynamically Stable Patients with Suspected Pulmonary Embolism
• For most patients with suspected PE who are hemodynamically stable, an approach that combines clinical and pretest probability
assessment, D-dimer testing, and definitive diagnostic imaging is usually applied.
• For a Patient with a Low Probability of PE (Wells Score <2)
• If PERC criteria are fulfilled, there is no need for further testing, and PE can be excluded. If PERC criteria are not met, then D-dimer
should be obtained. If D-dimer is negative(<500 ng/ml), PE can be ruled out if D-dimer is positive (>500 ng/ml) in patients age <50
or high after age-adjusted D-dimer value, CT pulmonary angiography should be performed. If CTPA is inconclusive or
contraindicated, V/Q scan should be performed.
• For a patient with intermediate probability of PE (Wells score 2 to 6)
• Measure D-dimer levels, if negative, PE can be excluded. If positive, then CTPA is done. If CTPA is inconclusive or contraindicated,
V/Q scan should be performed.
• For a Patient with a High Probability of PE (Wells Score >6)
• CTPA should be performed emergently. Feasibility requires adequate scanner technology, and the patient must be able to lie flat, to
cooperate with exam breath-holding instructions, have a body habitus that can fit into the scanner, and no contraindications for
iodinated contrast. If inconclusive or not feasible, perform a V/Q scan. V/Q scan could be normal, ruling out PE. It could also have
resulted as a "high probability for PE," which would be diagnostic of PE if V/Q scan results as intermediate probability, further
testing with lower extremity compression ultrasonography with Doppler is appropriate.
• For patients who are hemodynamically unstable and in whom definitive imaging is unsafe, bedside echocardiography or venous
compression ultrasound may be used to obtain a presumptive diagnosis of PE to justify the administration of potentially life-saving
therapies.
• Initial Management
• 1) The Supportive Measures
• The initial approach to patients with pulmonary embolism (PE) should focus on supportive measures.
• Supplemental oxygen is indicated in patients with oxygen saturation <90%. Mechanical ventilation (non-invasive or invasive)
should be utilized in unstable patients, but providers should be mindful of the adverse hemodynamic effects of mechanical
ventilation.
• Acute RV failure is the leading cause of death in patients with hemodynamically unstable PE. Aggressive volume resuscitation
in such patients can over distend the RV, worsen ventricular interdependence, and reduce cardiac output (CO). Hence, in
patients with massive PE, intravenous fluid resuscitation should be tried only in patients with collapsible IVC/intravascular
depletion. Vasopressors might be needed for hemodynamic support.
• Mechanical cardiopulmonary support devices, such as extracorporeal membrane oxygenation (ECMO), may be used in
hemodynamically unstable patients with pulmonary embolism.
• 2) Anticoagulation
• It is vital to remember that the mainstay of treatment of acute PE is anticoagulation.
• It is important to note that either low-molecular-weight heparin (LMWH) or fondaparinux or unfractionated heparin (UFH) can
be used for anticoagulation in acute PE. LMWH and fondaparinux are preferred since they have a less incidence of inducing
major bleeding and heparin-induced thrombocytopenia.[54][55] UFH is usually only used in patients with hemodynamic
instability in whom primary reperfusion treatment might be required, or in patients with renal impairment. Newer oral
anticoagulants (NOACs) and vitamin K antagonists(VKA) can also be used for anticoagulation in PE.
• For patients with suspected PE, the treatment is stratified according to the type of PE ( whether it is hemodynamically stable
or unstable PE) and according to the suspicion of PE in an individual patient. Patients are classified into low, intermediate, or
high suspicion for PE based on either revised Geneva or Wells score.
• Hemodynamically Stable Patients:
• Hemodynamically Unstable Patients:
• Patients with a high clinical suspicion for PE who are hemodynamically unstable, emergent CTPA, portable perfusion
scanning, or bedside transthoracic echocardiography should be performed whenever possible. Primary reperfusion
treatment, usually, thrombolysis, is the treatment of choice for patients with hemodynamically unstable acute PE. Surgical
pulmonary embolectomy or percutaneous catheter-directed therapy are alternative reperfusion options in patients with
contraindications to thrombolysis. Following reperfusion treatment and hemodynamic stabilization, patients recovering from
high-risk PE can be switched from parenteral to oral anticoagulation.
• 3) Reperfusion Strategies
• Thrombolysis:
• Thrombolysis has shown an effective reduction in pulmonary artery pressure and resistance in patients with PE when
compared with UFH alone; these improvements are assessed by a decrease in RV dilation on echocardiography.[56][57]
Thrombolysis is preferred when therapy can be instituted within 48 hours of symptom onset, but it has still shown benefit in
patients whose symptoms began less than 14 days ago.[58] A meta-analysis suggested a significant reduction in mortality and
recurrent PE with the use of thrombolytics.[59]
• Pulmonary Embolism Thrombolysis (PEITHO) trial identified the benefits of thrombolysis in hemodynamically stable patients
with intermediate-risk PE.[60] It demonstrated that thrombolysis was associated with a significant reduction in the risk of
hemodynamic decompensation or collapse, but it also showed an increased risk of severe bleeding with thrombolytics.
[60][61]
• Absolute contraindications to thrombolysis include any prior intracranial hemorrhage, known structural intracranial
cerebrovascular disease (e.g., arteriovenous malformation), known malignant intracranial neoplasm, ischemic stroke within
three months, suspected aortic dissection, active bleeding or bleeding diathesis, recent surgery encroaching on the spinal
canal or brain, and recent significant closed-head or facial trauma with radiographic evidence of bony fracture or brain inju
• Catheter-Directed Treatment:
• Involves the insertion of a catheter into the pulmonary arteries, which is then used for ultrasound-assisted
thrombolysis, suction embolectomy, rotational embolectomy, thrombus aspiration, or combining mechanical
fragmentation with pharmacological catheter-directed thrombolysis. Different studies have shown a success
rate of up to 87% for catheter-directed therapies.[62][63] Catheter-assisted embolectomy techniques carry
the inherent risk of perforating the pulmonary arteries, leading to massive hemoptysis or cardiac
tamponade. These complications are rare but fatal.
• Surgical Embolectomy
• It is usually indicated in a patient with hemodynamically unstable PE in whom thrombolysis (systemic or
catheter-directed) is contraindicated, or in patients who have failed thrombolysis.[64][65][66] Thrombolysis
or surgical embolectomy, there was no difference in mortality between the two, but the thrombolysis group
had a higher risk of stroke and re-intervention.
• Vena Cava Filters
• These block the path of travel of emboli and prevent them from entering the pulmonary circulation. Filters
are indicated in patients with venous thromboembolism who have an absolute contraindication to
anticoagulants, and in patients with recurrent VTE despite anticoagulation. Retrievable filters are preferred,
such that once the contraindication has resolved, the filter can be removed, and patients should be
anticoagulated. This is because, the Prevention of Recurrent Pulmonary Embolism by Vena Cava Interruption
(PREPIC) study showed that the insertion of a permanent vena cava filter was associated with a significant
reduction in the risk of recurrent PE and a substantial increase in the risk of DVT, without a remarkable
difference in the risk of recurrent VTE or death
• Chronic Treatment and Prevention of Recurrence
• The aim of anticoagulation after the acute management of PE is to complete the treatment of the acute episode and
also prevent the recurrence of VTE over the long-term. Clinical trials have assessed various durations of anticoagulant
therapy with vitamin K antagonists (VKAs) for VTE.[68][69][70] The findings of these studies have concluded the
following points. First, all patients with PE should receive three or more than three months of anticoagulant
treatment. Second, after the anticoagulant treatment is stopped, the risk of recurrence is expected to be similar if
anticoagulants are stopped after 3-6 months compared with longer treatment periods (e.g., 12-24 months). Third,
extended oral anticoagulant treatment reduces the risk of recurrent VTE by ≤90%, but the risk of bleeding partially
offsets this benefit. Oral anticoagulants are highly efficient in preventing recurrent VTE at the time of treatment, but
after the discontinuation of treatment, they do not eliminate the risk of subsequent recurrence.[68][68][68] It is
important to note that about 30% of PEs are unprovoked. Unprovoked PE ( PE in the absence of an identifiable risk
factor) is associated with a two- to three-fold increase in the risk of recurrence compared to patients who had a
provoked PE.[71] Patients with persistent risk factors (e.g., cancer or elevated antiphospholipid antibodies) have a
higher rater of recurrence than those with transient risk factors (e.g., immobilization, surgery, or trauma).[72]
• In conclusion, the optimal duration of anticoagulation remains uncertain and has to be considered on a case to case
basis. A minimum of 3 months is usually recommended, but a more extended period is required if the PE was
unprovoked or if there are persistent risk factors.[71] This need for longer anticoagulation should be assessed at the
end of 3 months by considering the patient's bleeding risk. Those with a high bleeding risk can limit therapy to three
months.
• Special considerations are required for patients with active cancer, given their increased risk for a VTE event. Hence,
cancer patients should receive an extended duration of anticoagulation if their bleeding risk remains acceptable ( low
or moderate bleeding risk). For cancer patients with PE, LMWH, and DOACs (apixaban, rivaroxaban) are preferred
over VKA.[73]