Acute pulmonary embolism

Abstract

Pulmonary embolism (PE) is a common and life-threatening cardiovascular emergency. It is a major cause of morbidity and mortality associated with surgery, injury, and medical illnesses. However, PE may occur in patients without any identifiable predisposing factors. The first and most crucial step in the diagnosis of PE is evaluating the likelihood of the disease based on clinical presentation. The appropriate diagnostic algorithm and the interpretation of diagnostic tests will depend on clinical probability of PE. For normotensive patients with clinically suspected PE, multidetector CT pulmonary angiography is currently the most frequently performed imaging test. Current guidelines emphasize the need to combine this test with assessment of clinical probability and D-dimer testing. As a general rule, anticoagulation with heparin should be initiated without delay in all patients with confirmed PE and should be considered in patients with an intermediate or high clinical probability while awaiting the results of further diagnostic confirmation. Thrombolytic agents rapidly resolve thrombus-related vascular obstruction providing instant hemodynamic relief in the majority of patients with massive PE. For patients with massive PE, in whom thrombolysis has failed or is absolutely contraindicated, surgical embolectomy or alternatively percutaneous catheter thrombectomy is recommended as a lifesaving treatment option. Oral anticoagulants (vitamin K antagonists) should be initiated as soon as possible in all hemodynamically stable patients, preferably on the same day as heparin. New oral anticoagulants seem to be as effective as vitamin K antagonists for the treatment and prevention of venous thromboembolism and PE with possibly improved safety profiles.