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Int J Angiol 2024; 33(02): 082-088
DOI: 10.1055/s-0044-1786878
Review Article

Clinical Presentation and Risk Stratification of Pulmonary Embolism

Abdul Qudoos Iqbal Mohammed
1   Department of Cardiology, Nassau University Medical Center, East Meadow, NY
,
Lorin Berman
1   Department of Cardiology, Nassau University Medical Center, East Meadow, NY
,
Mark Staroselsky
1   Department of Cardiology, Nassau University Medical Center, East Meadow, NY
,
Peter Wenn 
1   Department of Cardiology, Nassau University Medical Center, East Meadow, NY
,
Ofek Hai
1   Department of Cardiology, Nassau University Medical Center, East Meadow, NY
,
Amgad N. Makaryus 
1   Department of Cardiology, Nassau University Medical Center, East Meadow, NY
2   Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
,
Roman Zeltser
1   Department of Cardiology, Nassau University Medical Center, East Meadow, NY
2   Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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Abstract

Pulmonary embolism (PE) presents with a spectrum of symptoms, ranging from asymptomatic cases to life-threatening events. Common symptoms include sudden dyspnea, chest pain, limb swelling, syncope, and hemoptysis. Clinical presentation varies based on thrombus burden, demographics, and time to presentation. Diagnostic evaluation involves assessing symptoms, physical examination findings, and utilizing laboratory tests, including D-dimer. Risk stratification using tools like Wells score, Pulmonary Embolism Severity Index, and Hestia criteria aids in determining the severity of PE. PE is categorized based on hemodynamic status, temporal patterns, and anatomic locations of emboli to guide in making treatment decisions. Risk stratification plays a crucial role in directing management strategies, with elderly and comorbid individuals at higher risk. Early identification and appropriate risk stratification are essential for effective management of PE. As we delve into this review article, we aim to enhance the knowledge base surrounding PE, contributing to improved patient outcomes through informed decision-making in clinical practice.

Keywords

pulmonary embolism - deep vein thrombosis - syncope - sudden cardiac arrest - wells score - right ventricular dysfunction - shock


Publication History

Article published online:
13 May 2024

© 2024. International College of Angiology. This article is published by Thieme.

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

 

  • References

  • 1 Sritharan SB, Raj CP, Ta V, Pandurangan N, Shinde V. “The Great Masquerader”: an interesting case series of pulmonary thromboembolism. Cureus 2022; 14 (12) e32330
    PubMedSearch in Google Scholar
  • 2 Bauersachs RM. Clinical presentation of deep vein thrombosis and pulmonary embolism. Best Pract Res Clin Haematol 2012; 25 (03) 243-251
    CrossrefPubMedSearch in Google Scholar
  • 3 Miniati M, Cenci C, Monti S, Poli D. Clinical presentation of acute pulmonary embolism: survey of 800 cases. PLoS One 2012; 7 (02) e30891
    CrossrefPubMedSearch in Google Scholar
  • 4 Stein PD, Terrin ML, Hales CA. et al. Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest 1991; 100 (03) 598-603
    CrossrefPubMedSearch in Google Scholar
  • 5 Stein PD, Beemath A, Matta F. et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med 2007; 120 (10) 871-879
    CrossrefPubMedSearch in Google Scholar
  • 6 Vyas V, Goyal A. Acute Pulmonary Embolism. In: StatPearls. Treasure Island, FL: StatPearls Publishing; ; August 8, 2022
  • 7 Stein PD, Henry JW. Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes. Chest 1997; 112 (04) 974-979
    CrossrefPubMedSearch in Google Scholar
  • 8 Calvo-Romero JM, Pérez-Miranda M, Bureo-Dacal P. Wheezing in patients with acute pulmonary embolism with and without previous cardiopulmonary disease. Eur J Emerg Med 2003; 10 (04) 288-289
    CrossrefPubMedSearch in Google Scholar
  • 9 Barco S, Ende-Verhaar YM, Becattini C. et al. Differential impact of syncope on the prognosis of patients with acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2018; 39 (47) 4186-4195
    CrossrefPubMedSearch in Google Scholar
  • 10 Castelli R, Tarsia P, Tantardini C, Pantaleo G, Guariglia A, Porro F. Syncope in patients with pulmonary embolism: comparison between patients with syncope as the presenting symptom of pulmonary embolism and patients with pulmonary embolism without syncope. Vasc Med 2003; 8 (04) 257-261
    CrossrefPubMedSearch in Google Scholar
  • 11 Coen M, Leuchter I, Sussetto M, Banfi C, Giraud R, Bendjelid K. Progressive dysphonia: Ortner syndrome. Am J Med 2018; 131 (12) e494-e495
    CrossrefPubMedSearch in Google Scholar
  • 12 den Exter PL, van Es J, Erkens PM. et al. Impact of delay in clinical presentation on the diagnostic management and prognosis of patients with suspected pulmonary embolism. Am J Respir Crit Care Med 2013; 187 (12) 1369-1373
    CrossrefPubMedSearch in Google Scholar
  • 13 Stein PD, Matta F, Musani MH, Diaczok B. Silent pulmonary embolism in patients with deep venous thrombosis: a systematic review. Am J Med 2010; 123 (05) 426-431
    CrossrefPubMedSearch in Google Scholar
  • 14 Courtney DM, Sasser HC, Pincus CL, Kline JA. Pulseless electrical activity with witnessed arrest as a predictor of sudden death from massive pulmonary embolism in outpatients. Resuscitation 2001; 49 (03) 265-272
    CrossrefPubMedSearch in Google Scholar
  • 15 Courtney DM, Kline JA. Prospective use of a clinical decision rule to identify pulmonary embolism as likely cause of outpatient cardiac arrest. Resuscitation 2005; 65 (01) 57-64
    CrossrefPubMedSearch in Google Scholar
  • 16 Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J 2000; 21 (16) 1301-1336
    CrossrefPubMedSearch in Google Scholar
  • 17 Kucher N, Goldhaber SZ. Management of massive pulmonary embolism. Circulation 2005; 112 (02) e28-e32
    CrossrefPubMedSearch in Google Scholar
  • 18 Stein PD, Goldhaber SZ, Henry JW, Miller AC. Arterial blood gas analysis in the assessment of suspected acute pulmonary embolism. Chest 1996; 109 (01) 78-81
    CrossrefPubMedSearch in Google Scholar
  • 19 Stein PD, Goldhaber SZ, Henry JW. Alveolar-arterial oxygen gradient in the assessment of acute pulmonary embolism. Chest 1995; 107 (01) 139-143
    CrossrefPubMedSearch in Google Scholar
  • 20 Meyer T, Binder L, Hruska N, Luthe H, Buchwald AB. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction. J Am Coll Cardiol 2000; 36 (05) 1632-1636
    CrossrefPubMedSearch in Google Scholar
  • 21 Giannitsis E, Müller-Bardorff M, Kurowski V. et al. Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism. Circulation 2000; 102 (02) 211-217
    CrossrefPubMedSearch in Google Scholar
  • 22 Horlander KT, Leeper KV. Troponin levels as a guide to treatment of pulmonary embolism. Curr Opin Pulm Med 2003; 9 (05) 374-377
    CrossrefPubMedSearch in Google Scholar
  • 23 Mikulewicz M, Lewczuk J. Importance of cardiac biomarkers in risk stratification in acute pulmonary embolism. Cardiol J 2008; 15 (01) 17-20
    PubMedSearch in Google Scholar
  • 24 Söhne M, Ten Wolde M, Boomsma F, Reitsma JB, Douketis JD, Büller HR. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemost 2006; 4 (03) 552-556
    CrossrefPubMedSearch in Google Scholar
  • 25 Kiely DG, Kennedy NS, Pirzada O, Batchelor SA, Struthers AD, Lipworth BJ. Elevated levels of natriuretic peptides in patients with pulmonary thromboembolism. Respir Med 2005; 99 (10) 1286-1291
    CrossrefPubMedSearch in Google Scholar
  • 26 Bĕlohlávek J, Dytrych V, Linhart A. Pulmonary embolism, part I: epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. Exp Clin Cardiol 2013; 18 (02) 129-138
    PubMedSearch in Google Scholar
  • 27 Jaff MR, McMurtry MS, Archer SL. et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, American Heart Association Council on Peripheral Vascular Disease, American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. [published correction appears in Circulation. 2012 Aug 14;126(7):e104] [published correction appears in Circulation. 2012 Mar 20;125(11):e495] Circulation 2011; 123 (16) 1788-1830
    CrossrefPubMedSearch in Google Scholar
  • 28 Sista AK, Kuo WT, Schiebler M, Madoff DC. Stratification, imaging, and management of acute massive and submassive pulmonary embolism. Radiology 2017; 284 (01) 5-24
    CrossrefPubMedSearch in Google Scholar
  • 29 Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE. Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. Radiology 1993; 189 (01) 133-136
    CrossrefPubMedSearch in Google Scholar
  • 30 Wells PS, Ginsberg JS, Anderson DR. et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998; 129 (12) 997-1005
    CrossrefPubMedSearch in Google Scholar
  • 31 Wells PS, Anderson DR, Rodger M. et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 2000; 83 (03) 416-420
    Thieme ConnectPubMedSearch in Google Scholar
  • 32 van Belle A, Büller HR, Huisman MV. et al; Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 2006; 295 (02) 172-179
    CrossrefPubMedSearch in Google Scholar
  • 33 Wells PS, Anderson DR, Rodger M. et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med 2001; 135 (02) 98-107
    CrossrefPubMedSearch in Google Scholar
  • 34 Kline JA, Courtney DM, Kabrhel C. et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost 2008; 6 (05) 772-780
    CrossrefPubMedSearch in Google Scholar
  • 35 Singh B, Mommer SK, Erwin PJ, Mascarenhas SS, Parsaik AK. Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism–revisited: a systematic review and meta-analysis. Emerg Med J 2013; 30 (09) 701-706
    CrossrefPubMedSearch in Google Scholar
  • 36 Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med 2001; 161 (01) 92-97
    CrossrefPubMedSearch in Google Scholar
  • 37 Le Gal G, Righini M, Roy PM. et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 2006; 144 (03) 165-171
    CrossrefPubMedSearch in Google Scholar
  • 38 Klok FA, Mos IC, Nijkeuter M. et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med 2008; 168 (19) 2131-2136
    CrossrefPubMedSearch in Google Scholar
  • 39 Klok FA, Kruisman E, Spaan J. et al. Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism. J Thromb Haemost 2008; 6 (01) 40-44
    CrossrefPubMedSearch in Google Scholar
  • 40 Penaloza A, Melot C, Motte S. Comparison of the Wells score with the simplified revised Geneva score for assessing pretest probability of pulmonary embolism. Thromb Res 2011; 127 (02) 81-84
    CrossrefPubMedSearch in Google Scholar
  • 41 Shen JH, Chen HL, Chen JR, Xing JL, Gu P, Zhu BF. Comparison of the Wells score with the revised Geneva score for assessing suspected pulmonary embolism: a systematic review and meta-analysis. J Thromb Thrombolysis 2016; 41 (03) 482-492
    CrossrefPubMedSearch in Google Scholar
  • 42 Di Marca S, Cilia C, Campagna A. et al. Comparison of Wells and revised Geneva rule to assess pretest probability of pulmonary embolism in high-risk hospitalized elderly adults. J Am Geriatr Soc 2015; 63 (06) 1091-1097
    CrossrefPubMedSearch in Google Scholar
  • 43 Konstantinides SV, Meyer G, Becattini C. et al; The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): the Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J 2019; 54 (03) 1901647
    CrossrefPubMedSearch in Google Scholar
  • 44 Russell C, Keshavamurthy S, Saha S. Classification and stratification of pulmonary embolisms. Int J Angiol 2022; 31 (03) 162-165
    Thieme ConnectPubMedSearch in Google Scholar
  • 45 Giri J, Sista AK, Weinberg I. et al. Interventional therapies for acute pulmonary embolism: current status and principles for the development of novel evidence: a scientific statement from the American Heart Association. Circulation 2019; 140 (20) e774-e801
    CrossrefPubMedSearch in Google Scholar
  • 46 Becattini C, Agnelli G, Lankeit M. et al. Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model. Eur Respir J 2016; 48 (03) 780-786
    CrossrefPubMedSearch in Google Scholar
  • 47 Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353 (9162) 1386-1389
    CrossrefPubMedSearch in Google Scholar
  • 48 Meinel FG, Nance Jr JW, Schoepf UJ. et al. Predictive value of computed tomography in acute pulmonary embolism: systematic review and meta-analysis. Am J Med 2015; 128 (07) 747-59.e2
    CrossrefPubMedSearch in Google Scholar
  • 49 Riedel M. Acute pulmonary embolism 1: pathophysiology, clinical presentation, and diagnosis. Heart 2001; 85 (02) 229-240
    CrossrefPubMedSearch in Google Scholar
  • 50 Aujesky D, Obrosky DS, Stone RA. et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005; 172 (08) 1041-1046
    CrossrefPubMedSearch in Google Scholar
  • 51 Donzé J, Le Gal G, Fine MJ. et al. Prospective validation of the Pulmonary Embolism Severity Index. a clinical prognostic model for pulmonary embolism. Thromb Haemost 2008; 100 (05) 943-948
    Thieme ConnectPubMedSearch in Google Scholar
  • 52 Jiménez D, Aujesky D, Moores L. et al; RIETE Investigators. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010; 170 (15) 1383-1389
    CrossrefPubMedSearch in Google Scholar
  • 53 Zondag W, Mos IC, Creemers-Schild D. et al; Hestia Study Investigators. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost 2011; 9 (08) 1500-1507
    CrossrefPubMedSearch in Google Scholar
  • 54 Zondag W, Vingerhoets LM, Durian MF. et al; Hestia Study Investigators. Hestia criteria can safely select patients with pulmonary embolism for outpatient treatment irrespective of right ventricular function. J Thromb Haemost 2013; 11 (04) 686-692
    CrossrefPubMedSearch in Google Scholar
  • 55 Roy PM, Penaloza A, Hugli O. et al; HOME-PE Study Group. Triaging acute pulmonary embolism for home treatment by Hestia or simplified PESI criteria: the HOME-PE randomized trial. Eur Heart J 2021; 42 (33) 3146-3157
    CrossrefPubMedSearch in Google Scholar