Pulmonary embolism echocardiography: Difference between revisions

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| [[File:Siren.gif|30px|link=Pulmonary embolism resident survival guide]]|| <br> || <br>
| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{Pulmonary embolism}}
{{Pulmonary embolism}}
 
'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; {{AE}} {{Rim}}
{{CMG}}; '''Associate Editors-in-Chief:''' [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]


==Overview==
==Overview==
Approximately 40% of patients with PE have evidence of right heart strain on echocardiography.  
Routine [[echocardiography]] in patients with suspected [[pulmonary embolism]] (PE) is not required.<ref name="pmid11992305">{{cite journal| author=Goldhaber SZ| title=Echocardiography in the management of pulmonary embolism. | journal=Ann Intern Med | year= 2002 | volume= 136 | issue= 9 | pages= 691-700 | pmid=11992305 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11992305  }} </ref>  In fact, the majority of patients with PE have a normal [[echocardiography]].<ref name="pmid11992305">{{cite journal| author=Goldhaber SZ| title=Echocardiography in the management of pulmonary embolism. | journal=Ann Intern Med | year= 2002 | volume= 136 | issue= 9 | pages= 691-700 | pmid=11992305 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11992305  }} </ref> However if elevations in the [[troponin|cardiac troponins]] or [[brain natriuretic peptide]] are present, then acute [[right ventricular dysfunction|right ventricular (RV) dysfunction]] may be present and echocardiography is warranted.<ref>{{cite journal |author=Kucher N, Goldhaber SZ |title=Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism |journal=Circulation |volume=108 |issue=18 |pages=2191-4 |year=2003|pmid=14597581|doi=10.1161/01.CIR.0000100687.99687.CE}}</ref> [[Echocardiography]] is also valuable for the evaluation of hemodynamically unstable patients with acute [[dyspnea]], [[right heart failure]], or [[syncope]] who are suspected to have PE.<ref name="pmid11992305">{{cite journal| author=Goldhaber SZ| title=Echocardiography in the management of pulmonary embolism. | journal=Ann Intern Med | year= 2002 | volume= 136 | issue= 9 | pages= 691-700 | pmid=11992305 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11992305  }} </ref>  The presence of [[right ventricular dysfunction]] is a predictor of early death among patients with PE.<ref name="pmid10227218">{{cite journal| author=Goldhaber SZ, Visani L, De Rosa M| title=Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER) | journal=Lancet | year= 1999 | volume= 353 | issue= 9162 | pages= 1386-9 | pmid=10227218 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10227218  }} </ref>  When evidence of [[RV dysfunction]] is present, PE is risk stratified into submassive PE or massive PE depending on the absence or presence of [[hypotension]] respectively.<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref><ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref>
[[RV dysfunction]] and RV [[thrombus]] on echocardiography help in assessing prognosis.


==Echocardiography==
==Echocardiography==
In massive and submassive PE, dysfunction of the right side of the heart can be seen on [[echocardiography]], an indication that the [[pulmonary artery]] is severely obstructed and the heart is unable to match the pressure. Some studies suggest that this finding may be an indication for [[thrombolysis]]. Not every patient with a (suspected) pulmonary embolism requires an echocardiogram, but elevations in [[troponin|cardiac troponins]] or [[brain natriuretic peptide]] may indicate heart strain and warrant an echocardiogram.<ref>{{cite journal |author=Kucher N, Goldhaber SZ |title=Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism |journal=Circulation |volume=108 |issue=18 |pages=2191-4 |year=2003 |pmid=14597581 |doi=10.1161/01.CIR.0000100687.99687.CE}}</ref>
* In massive and submassive PE, [[RV dysfunction]] seen on [[echocardiography]] may indicate that the [[pulmonary artery]] is severely obstructed and that the heart is unable to compensate. Some studies suggest that this finding may be an indication for [[thrombolysis]]. The presence of [[RV dysfunction]] is a predictor of early death among patients with PE.<ref name="pmid10227218">{{cite journal| author=Goldhaber SZ, Visani L, De Rosa M| title=Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER) | journal=Lancet | year= 1999 | volume= 353 | issue= 9162 | pages= 1386-9 | pmid=10227218 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10227218  }} </ref>


The specific appearance of the right ventricle on echocardiography is referred to as the ''McConnell sign''. This is the finding of akinesia of the mid-free wall but normal motion of the apex. This phenomenon has a 77% sensitivity and a 94% specificity for the diagnosis of acute pulmonary embolism.<ref>{{cite journal |author=McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT |title=Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=4 |pages=469-73 |year=1996 |pmid=8752195 |doi=}}</ref>.
*[[Echocardiography]] findings that are indicative of [[RV dysfunction]] are mainly:<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref><ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref>
** [[RV]] dilation (ratio of apical 4-chamber [[RV]] diameter to [[LV|left ventricle (LV)]] diameter > 0.9)
** [[RV]] systolic dysfunction


[[Echocardiography]] should be used to confirm the presence of [[right ventricular dysfunction]] if multidetector CT is not available.
* Other echocardiographic findings that are supportive of the presence of [[RV dysfunction]] include:<ref name="pmid11992305">{{cite journal| author=Goldhaber SZ| title=Echocardiography in the management of pulmonary embolism. | journal=Ann Intern Med | year= 2002 | volume= 136 | issue= 9 | pages= 691-700 | pmid=11992305 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11992305  }} </ref>
** Paradoxical [[interventricular septum|intraventricular septal]] motion
** [[Tricuspid regurgitation]]
** [[Pulmonary artery]] hypertension (systolic pulmonary artery pressure over 30 mmHg)
** [[Patent foramen ovale]] (might occur when the pressure in the [[right atria]] is higher than that in the [[left atrium]])


The diagnosis of [[right ventricular dysfunction]] required the presence of at least two out of these, though in absence of [[right ventricular hypertrophy]]<ref name="pmid10859287">{{cite journal| author=Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G et al.| title=Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. | journal=Circulation | year= 2000 | volume= 101 | issue= 24 | pages= 2817-22 | pmid=10859287 | doi= | pmc= | url= }} </ref><ref name="pmid19910608">{{cite journal| author=Sanchez O, Trinquart L, Caille V, Couturaud F, Pacouret G, Meneveau N et al.| title=Prognostic factors for pulmonary embolism: the prep study, a prospective multicenter cohort study. | journal=Am J Respir Crit Care Med | year= 2010 | volume= 181 | issue= 2 | pages= 168-73 | pmid=19910608 | doi=10.1164/rccm.200906-0970OC | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19910608 }} </ref>:
* Echocardiography may also show akinesia of the mid-free wall but normal apical motion of the right ventricle. This is referred to as the McConnell sign. The [[sensitivity]] and [[specificity]] of the McConnell sign for the diagnosis of acute PE are 77% and 94% respectively.<ref>{{cite journal |author=McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT |title=Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=4 |pages=469-73 |year=1996 |pmid=8752195 |doi=}}</ref>
# Right-to-Left ventricular end diastolic diameter ratio>0.9 in the apical four-chamber view.
 
# Right-to-Left ventricular end diastolic diameter ratio>0.7 in the parasternal long-axis or subcoastel four-chamber view.
Shown below is an echocardiogram that demonstrates McConnell sign:
# Paradoxical interventricular septal motion
{{#ev:youtube|Tklaxe-kPrk}}
# Systolic pulmonary artery pressure over 30 mmHg.
 
* In addition, echocardiography findings that are associated with worse prognosis include:
** [[RV dysfunction]]<ref name="pmid10227218">{{cite journal| author=Goldhaber SZ, Visani L, De Rosa M| title=Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER) | journal=Lancet | year= 1999 | volume= 353 | issue= 9162 | pages= 1386-9 | pmid=10227218 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10227218  }} </ref>
** Right heart [[thrombus]]<ref name="pmid12821255">{{cite journal| author=Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ et al.| title=Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 12 | pages= 2245-51 | pmid=12821255 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12821255 }} </ref>
** [[Patent foramen ovale]]<ref name="pmid9609088">{{cite journal |author=Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H |title=Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism |journal=Circulation |volume=97 |issue=19 |pages=1946–51 |year=1998 |month=May |pmid=9609088 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=9609088 |accessdate=2011-12-21}}</ref>
 
* [[Echocardiography]] should be used to confirm the presence of [[RV dysfunction]] if multidetector CT is not available.


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
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[[Category:Cardiology]]
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[[Category:Emergency medicine]]
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[[Category:Intensive care medicine]]
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Latest revision as of 23:53, 29 July 2020
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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

Routine echocardiography in patients with suspected pulmonary embolism (PE) is not required.[1] In fact, the majority of patients with PE have a normal echocardiography.[1] However if elevations in the cardiac troponins or brain natriuretic peptide are present, then acute right ventricular (RV) dysfunction may be present and echocardiography is warranted.[2] Echocardiography is also valuable for the evaluation of hemodynamically unstable patients with acute dyspnea, right heart failure, or syncope who are suspected to have PE.[1] The presence of right ventricular dysfunction is a predictor of early death among patients with PE.[3] When evidence of RV dysfunction is present, PE is risk stratified into submassive PE or massive PE depending on the absence or presence of hypotension respectively.[4][5]

Echocardiography

  • Echocardiography may also show akinesia of the mid-free wall but normal apical motion of the right ventricle. This is referred to as the McConnell sign. The sensitivity and specificity of the McConnell sign for the diagnosis of acute PE are 77% and 94% respectively.[6]

Shown below is an echocardiogram that demonstrates McConnell sign: {{#ev:youtube|Tklaxe-kPrk}}

References

  1. ↑ 1.0 1.1 1.2 1.3 Goldhaber SZ (2002). "Echocardiography in the management of pulmonary embolism". Ann Intern Med. 136 (9): 691–700. PMID 11992305.
  2. ↑ Kucher N, Goldhaber SZ (2003). "Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism". Circulation. 108 (18): 2191–4. doi:10.1161/01.CIR.0000100687.99687.CE. PMID 14597581.
  3. ↑ 3.0 3.1 3.2 Goldhaber SZ, Visani L, De Rosa M (1999). "Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER)". Lancet. 353 (9162): 1386–9. PMID 10227218.
  4. ↑ 4.0 4.1 Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.
  5. ↑ 5.0 5.1 Cannon CP, Goldhaber SZ (1996). "Cardiovascular risk stratification of pulmonary embolism". Am. J. Cardiol. 78 (10): 1149–51. PMID 8914880. Retrieved 2011-12-21. Unknown parameter |month= ignored (help)
  6. ↑ McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT (1996). "Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism". Am. J. Cardiol. 78 (4): 469–73. PMID 8752195.
  7. ↑ Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ; et al. (2003). "Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry". J Am Coll Cardiol. 41 (12): 2245–51. PMID 12821255.
  8. ↑ Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H (1998). "Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism". Circulation. 97 (19): 1946–51. PMID 9609088. Retrieved 2011-12-21. Unknown parameter |month= ignored (help)

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