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Pulmonary Embolism: Current Concepts in Diagnosis and Management. Gregory Piazza, MD July 26, 2005. Objectives. To examine the state-of-the-art in the evaluation of patients with suspected pulmonary embolism (PE). To review the recent advances in risk stratification of patients with PE.
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Gregory Piazza, MD
July 26, 2005
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How should this patient be worked up?
Lower extremity ultrasound
Ventilation-perfusion lung scanning
Spiral chest CT
Magnetic resonance (MR) angiography
Contrast pulmonary angiographyThe Diagnostic Armamentarium
“Everything you can do is not everything you should do.”
Common electrocardiographic findings:
- cardiomegaly (27%)
- normal (24%)
- pleural effusion (23%)
- elevated hemidiaphragm (20%)
- pulmonary artery enlargement (19%)
- atelectasis (18%)
- pulmonary infiltrate (17%)
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Eval. clinical likelihood
Patient in ED
Inpatient or high prob.
V/Q if dye allergy or renal insufficiency
Treat for PE
No PEAn Integrated Approach
Did we see this coming?
Risk Stratification Tools:
RV dysfunction has proven to be one of the strongest predictors of adverse outcomes and recurrent PE.
Typical findings in PE include:
Moderate to severe RV free wall hypokinesis with apical sparing (McConnell Sign)
Paradoxical interventricular septal motion
Loss of respiratory-phasic changes in IVC
Decrease in the difference between LV area during diastole and systole (marker of cardiogenic shock)Echocardiography
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How should we manage this patient?
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Not High Risk
Consider 1˚ Therapy
Warfarin for 6 months
If idiopathic PE, continue anticoagulation indefinitely
Stop if PE was caused by surgery or trauma
Bauer K. Pentasaccharides. October 16, 2003.
PE or recurrent PE despite adequate anticoagulation
Patients with contraindications to anticoagulation
Open surgical pulmonary embolectomy
Do not address the thrombotic process
Peripheral leg edema can ensue
Large venous collaterals can develop and permit PE
Filters may be deployed improperly or have technical problems
Increased incidence of DVT (at 2 years, 21% v. 12%, p=0.02)
No survival benefitInferior Vena Cava (IVC) Filters
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