Clinical and hemodynamic spectrum, diagnosis, and treatment of acute pulmonary embolism: The aggressive approach

Abstract

A total of 132 consecutive patients underwent centralized treatment of acute symptomatic pulmonary embolism during the period 1975–1987. The spectrum ranged from patients with minor peripheral emboli to those with massive central emboli causing cardiocirculatory collapse. The patients were treated with full-dose heparin (N = 41), streptokinase (N = 52), or embolectomy during extracorporeal circulation (N = 39). The duration of symptoms (zero to sixty days), number of embolic episodes before the diagnosis, degree of circulatory affection, abnormalities on chest radiography, arterial blood gases, and electrocardiographic (ECG) findings were analyzed in relation to underlying diseases as well as to degree of pulmonary vascular obstruction (scintigraphic/angiographic embolic score). Systolic pulmonary artery pressure (SPAP) correlated directly with duration of symptoms; the highest SPAP (>70 mmHg) was found in patients with symptoms lasting more than one week, which, irrespective of embolic score and choice of treatment, involved a definite risk of later development of chronic cor pulmonale. SPAP correlated directly with embolic score only after exclusion of patients with symptoms lasting more than a week and with preexisting cardiopulmonary disease. The majority of patients with circulatory collapse had had a reversible shock hours to days previously, which further underlines the necessity of an aggressive diagnostic and therapeutic attitude. ECG signs of acute right ventricular strain and sinus tachycardia reflected both massive and short-lasting embolization and are now used routinely to indicate emergency pulmonary arteriography (rather than ventilation-perfusion scintigraphy) in the diagnostic approach.

Based on previous results, the authors' indications for embolectomy were in 1984 broadened to include all patients with central emboli (less than one week old), including those who were cardiocirculatorily stable. In the present evaluation, multivariate risk analysis in total patient series as well as in patients with central emboli showed that medical treatment (heparin and streptokinase as opposed to embolectomy) independently increased the mortality rate. This was confirmed by a matched analysis of embolectomy versus streptokinase treatment in patients with central fresh emboli and no circulatory collapse. A diagnostic strategy and indications for treatment representing an aggressive approach are advocated.