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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}}
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'''Associate Editors-in-Chief:''' [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]
'''''Synonyms and keywords:''''' PE
==Overview==
==Overview==
Pulmonary embolism (PE) is classified in two different ways based upon:
Pulmonary embolism (PE) can be classified based on the time course of symptom presentation (acute and chronic) and the overall severity of disease (stratified based upon three levels of risk: massive, submassive, and low-risk).  Massive PE is characterised by the presence of either sustained [[hypotension]], or [[PEA|pulselessness]], or [[bradycardia]].  Submassive PE is characterized by the presence of either [[Pulmonary embolism classification#Right Ventricular Dysfunction|right ventricular dysfunction]] or [[Pulmonary embolism classification#Myocardial Necrosis|myocardial necrosis]] in the absence of [[hypotension]]. In low risk PE, there is absence of [[hypotension]], [[shock]], [[Pulmonary embolism classification#Right Ventricular Dysfunction|right ventricular dysfunction]] and [[Pulmonary embolism classification#Myocardial Necrosis|myocardial necrosis]].<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>
# Time of appearance of symptoms & size of [[Emboli|embolus]] : '''Acute''' vs '''Chronic
 
# Severity of the disease : '''Massive''' vs '''Submassive''' vs '''Low-risk'''
==Classification Based on Acuity==
 
===Acute Pulmonary Embolism===
Acute PE is the sudden obstruction of the pulmonary arteries by an embolism, which may result in the immediate occurrence of symptoms.  Acute PE can be either silent, symptomatic, or fatal.  Acute PE can also classified by its severity (as discussed below) as [[Pulmonary embolism classification#Massive PE|massive PE]], [[Pulmonary embolism classification#Submassive PE|submassive PE]], or [[Pulmonary embolism classification#Low-risk PE|low-risk PE]].
 
===Chronic Pulmonary Embolism===
Chronic PE, referred to as chronic thromboembolic pulmonary hypertension, is the presence of persistent [[pulmonary hypertension]] for at least 6 months following acute [[PE]].<ref name="pmid21268727">{{cite journal| author=Piazza G, Goldhaber SZ| title=Chronic thromboembolic pulmonary hypertension. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 4 | pages= 351-60 | pmid=21268727 | doi=10.1056/NEJMra0910203 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21268727  }} </ref>  The episode of acute PE preceding the chronic thromboembolic pulmonary hypertension can be either symptomatic or asymptomatic.<ref name="pmid24898750">{{cite journal| author=Hoeper MM, Madani MM, Nakanishi N, Meyer B, Cebotari S, Rubin LJ| title=Chronic thromboembolic pulmonary hypertension. | journal=Lancet Respir Med | year= 2014 | volume=  | issue=  | pages=  | pmid=24898750 | doi=10.1016/S2213-2600(14)70089-X | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24898750  }} </ref>
 
==Classification Based on Disease Severity ==
In addition to the time of presentation and the size of the [[embolus]], a PE can also be classified based on the severity of disease. PE can be classified into three types based on the severity: massive (5-10% of cases), submassive (20-25% of cases), and low-risk (70% of cases).
 
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
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| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 30%" align=center |'''Classification of PE by Severity'''||style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF" align=center |'''Criteria'''<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>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Massive PE''' <br> '''''(also known as high risk PE)''''' || style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |- Sustained [[hypotension]] (systolic blood pressure <90 mm Hg), not due to [[arrhythmia]], [[hypovolemia]], [[sepsis]], or [[left ventricular dysfunction]], and either lasting for at least 15 minutes or necessitating the administration of inotropes<br>
OR<br>
- [[PEA|Pulselessness]]<br>
OR<br>
- Persistent profound [[bradycardia]] (heart rate < 40 bpm) plus findings of [[shock]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Submassive PE''' <br> '''''(also known as intermediate risk PE)'''''|| style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |- [[Pulmonary embolism classification#Right Ventricular Dysfunction|Right ventricular dysfunction]] OR [[Pulmonary embolism classification#Myocardial Necrosis|myocardial necrosis]]<br>
AND <br>
- Absence of [[hypotension|systemic hypotension]] (systolic blood pressure >90 mm Hg)
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Low risk PE''' || style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |- Absence of [[hypotension]], [[shock]], [[Pulmonary embolism classification#Right Ventricular Dysfunction|right ventricular dysfunction]] and [[Pulmonary embolism classification#Myocardial Necrosis|myocardial necrosis]]
|-
|}
 
=== Massive Pulmonary Embolism ===
* Massive PE accounts for 5-10% of pulmonary emboli.
* Massive PE falls under the category "high risk patients" in the European guidelines. High risk PE patients have a risk of PE-related early mortality of > 15%.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute : the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>


==Acute PE==
* According to the [[American Heart Association]], massive PE is characterized by the presence of:
Pulmonary embolism is called acute, if the embolism is
Sustained [[hypotension]] (systolic blood pressure <90 mm Hg), not due to [[arrhythmia]], [[hypovolemia]], [[sepsis]], or [[left ventricular dysfunction]], and either lasting for at least 15 minutes or necessitating the administration of inotropes<br>
*Based on '''time''' of appearance of symptoms:
''OR''<br>
**Develop symptoms and signs '''immediately''' after obstruction of pulmonary vessels.
[[PEA|Pulselessness]]<br>
*Based on characteristic of the embolus:
''OR''<br>
**Situated centrally within the vascular lumen
Persistent profound [[bradycardia]] (heart rate < 40 bpm) plus findings of [[shock]]<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>
**Occludes a vessel
**It also causes distention of the involved vessel.  


Acute PE can be further classified as '''[[Pulmonary embolism classification scheme#Massive PE|massive pulmonary embolism]]''', '''[[Pulmonary embolism classification scheme#Submassive PE|submassive pulmonary embolism]]''' or '''[[Pulmonary embolism classification scheme#Low-risk PE|low-risk pulmonary embolism]]'''.
=== Submassive Pulmonary Embolism ===
* Submassive PE accounts for 20-25% of pulmonary emboli.


==Chronic PE==
* Submassive PE falls under the category "intermediate risk patients" in the European guidelines. Intermediate risk PE patients have a risk of PE-related early mortality ranging between 3 and 15%.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
Chronic pulmonary embolism is a consequence of incomplete resolution of pulmonary embolism. It can be characterized:
*Based on '''time''' of appearance of symptoms:
**Develop '''slowly''' progressive [[dyspnea]] over a period of years due to [[pulmonary hypertension]].


*Based on characteristic of the embolus<ref name="pmid19168835">{{cite journal| author=Castañer E, Gallardo X, Ballesteros E, Andreu M, Pallardó Y, Mata JM et al.| title=CT diagnosis of chronic pulmonary thromboembolism. | journal=Radiographics | year= 2009 | volume= 29 | issue= 1 | pages= 31-50; discussion 50-3 | pmid=19168835 | doi=10.1148/rg.291085061 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19168835  }} </ref>:
* According to the [[American Heart Association]], submassive PE is characterized by:
**Embolus is eccentric and Contiguous with the vessel wall
**Embolus reducing the arterial diameter by ≥50%
**Evidence of recanalization within the thrombus
**Presence of an arterial web


==Massive PE==
[[Pulmonary embolism classification#Right Ventricular Dysfunction|Right ventricular dysfunction]] OR [[Pulmonary embolism classification#Myocardial Necrosis|myocardial necrosis]]<br>
In the past, '''massive pulmonary embolism''' has been defined on the basis of angiographic burden of emboli by using the [[Miller Index]]<ref name="pmid5557502">{{cite journal| author=Miller GA, Sutton GC, Kerr IH, Gibson RV, Honey M| title=Comparison of streptokinase and heparin in treatment of isolated acute massive pulmonary embolism. | journal=Br Heart J | year= 1971 | volume= 33 | issue= 4 | pages= 616 | pmid=5557502 | doi= | pmc= | url= }} </ref>. This is a retrospective diagnosis based upon the pulmonary angiogram that does not inform prospective decisions.
''AND'' <br>
Absence of [[hypotension|systemic hypotension]] (systolic blood pressure >90 mm Hg)<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>  
* Submassive PE patients share the following characteristics:<ref name="pmid10077516">{{cite journal |author=Ribeiro A, Lindmarker P, Johnsson H, Juhlin-Dannfelt A, Jorfeldt L |title=Pulmonary embolism: one-year follow-up with echocardiography doppler and five-year survival analysis |journal=Circulation |volume=99 |issue=10 |pages=1325–30 |year=1999 |month=March |pmid=10077516 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=10077516 |accessdate=2011-12-21}}</ref><ref name="pmid19041539">{{cite journal |author=Fengler BT, Brady WJ |title=Fibrinolytic therapy in pulmonary embolism: an evidence-based treatment algorithm |journal=Am J Emerg Med |volume=27 |issue=1 |pages=84–95 |year=2009 |month=January |pmid=19041539 |doi=10.1016/j.ajem.2007.10.021 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(07)00699-7 |accessdate=2011-12-21}}</ref>
** A significantly higher rate of in-hospital complications.
** A higher potential for long-term [[pulmonary hypertension]] and cardiopulmonary disease.


Recently the [[American Heart Association]]<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> has proposed the following definition for massive PE: ''Acute pulmonary embolism with sustained [[hypotension]] (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as [[arrhythmia]], [[hypovolemia]], [[sepsis]], or left ventricular [LV] dysfunction), pulselessness, or persistent profound [[bradycardia]] (heart rate <40 bpm with signs or symptoms of shock).''
* Though patients with submassive pulmonary emboli may initially appear hemodynamically and clinically stable, there is potential to undergo a cycle of progressive [[right ventricular failure]]. A submassive PE requires continuous monitoring to prevent irreversible damage and death.<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>


==Submassive PE==
====Right Ventricular Dysfunction====
The [[American Heart Association]]<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> has proposed the following definition for submassive PE: '''"'''Acute PE without systemic [[hypotension]] (systolic [[blood pressure]] ≥90 mm Hg) but with either [[RV dysfunction]] or [[myocardial necrosis]].'''"'''
[[Right ventricular dysfunction|Right ventricular (RV) dysfunction]] is characterized by the presence of AT LEAST ONE of the following:<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>
*[[Echocardiography]] findings:
** [[RV]] dilation (ratio of apical 4-chamber [[RV]] diameter to [[LV|left ventricle (LV)]] diameter > 0.9)  
** [[RV]] systolic dysfunction
*[[CT]] findings: [[RV]] dilation (ratio of 4-chamber RV diameter to [[LV]] diameter > 0.9)
*[[BNP]] > 90 pg/mL
*[[N-terminal pro-BNP]] >500 pg/mL
*[[EKG]] findings:
** New complete or incomplete [[right bundle-branch block]]
** Anteroseptal [[ST elevation]] or [[ST depression]]
** Anteroseptal [[Inverted T wave|T-wave inversion]]


==Low-risk PE==
====Myocardial Necrosis====
The [[American Heart Association]]<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> has proposed the following definition for Low-risk PE: '''"'''Acute PE and the absence of the clinical markers of adverse prognosis that define massive or submassive PE.'''"'''
[[Myocardial necrosis]] is defined as the presence of:<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>
*Elevation of [[troponin I]] (>0.4 ng/mL)
''OR'' <br>
*Elevation of [[troponin T]] (>0.1 ng/mL)


==Saddle PE==
=== Low-Risk Pulmonary Embolism ===
A saddle PE is one that lodges at the bifurcation of the main [[pulmonary artery]] into the right and left pulmonary arteries. Most of the saddle PE are submassive.
* Low risk PE accounts for 70% of pulmonary emboli.
* Low risk PE patients have a risk of PE-related early mortality of <1%.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>  According to the [[American Heart Association]], low risk PE is characterized by the absence of [[hypotension]], [[shock]], [[Pulmonary embolism classification#Right Ventricular Dysfunction|right ventricular dysfunction]] and [[Pulmonary embolism classification#Myocardial Necrosis|myocardial necrosis]].<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>


==References==
==References==
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[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] The APEX Trial Investigators; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

Pulmonary embolism (PE) can be classified based on the time course of symptom presentation (acute and chronic) and the overall severity of disease (stratified based upon three levels of risk: massive, submassive, and low-risk). Massive PE is characterised by the presence of either sustained hypotension, or pulselessness, or bradycardia. Submassive PE is characterized by the presence of either right ventricular dysfunction or myocardial necrosis in the absence of hypotension. In low risk PE, there is absence of hypotension, shock, right ventricular dysfunction and myocardial necrosis.[1]

Classification Based on Acuity

Acute Pulmonary Embolism

Acute PE is the sudden obstruction of the pulmonary arteries by an embolism, which may result in the immediate occurrence of symptoms. Acute PE can be either silent, symptomatic, or fatal. Acute PE can also classified by its severity (as discussed below) as massive PE, submassive PE, or low-risk PE.

Chronic Pulmonary Embolism

Chronic PE, referred to as chronic thromboembolic pulmonary hypertension, is the presence of persistent pulmonary hypertension for at least 6 months following acute PE.[2] The episode of acute PE preceding the chronic thromboembolic pulmonary hypertension can be either symptomatic or asymptomatic.[3]

Classification Based on Disease Severity

In addition to the time of presentation and the size of the embolus, a PE can also be classified based on the severity of disease. PE can be classified into three types based on the severity: massive (5-10% of cases), submassive (20-25% of cases), and low-risk (70% of cases).

Classification of PE by Severity Criteria[1]
Massive PE
(also known as high risk PE)		 - Sustained hypotension (systolic blood pressure <90 mm Hg), not due to arrhythmia, hypovolemia, sepsis, or left ventricular dysfunction, and either lasting for at least 15 minutes or necessitating the administration of inotropes

OR
- Pulselessness
OR
- Persistent profound bradycardia (heart rate < 40 bpm) plus findings of shock

Submassive PE
(also known as intermediate risk PE)		 - Right ventricular dysfunction OR myocardial necrosis

AND
- Absence of systemic hypotension (systolic blood pressure >90 mm Hg)

Low risk PE - Absence of hypotension, shock, right ventricular dysfunction and myocardial necrosis

Massive Pulmonary Embolism

  • Massive PE accounts for 5-10% of pulmonary emboli.
  • Massive PE falls under the category "high risk patients" in the European guidelines. High risk PE patients have a risk of PE-related early mortality of > 15%.[4]

Sustained hypotension (systolic blood pressure <90 mm Hg), not due to arrhythmia, hypovolemia, sepsis, or left ventricular dysfunction, and either lasting for at least 15 minutes or necessitating the administration of inotropes
OR
Pulselessness
OR
Persistent profound bradycardia (heart rate < 40 bpm) plus findings of shock[1]

Submassive Pulmonary Embolism

  • Submassive PE accounts for 20-25% of pulmonary emboli.
  • Submassive PE falls under the category "intermediate risk patients" in the European guidelines. Intermediate risk PE patients have a risk of PE-related early mortality ranging between 3 and 15%.[4]

Right ventricular dysfunction OR myocardial necrosis
AND
Absence of systemic hypotension (systolic blood pressure >90 mm Hg)[1][5]

  • Submassive PE patients share the following characteristics:[6][7]
    • A significantly higher rate of in-hospital complications.
    • A higher potential for long-term pulmonary hypertension and cardiopulmonary disease.
  • Though patients with submassive pulmonary emboli may initially appear hemodynamically and clinically stable, there is potential to undergo a cycle of progressive right ventricular failure. A submassive PE requires continuous monitoring to prevent irreversible damage and death.[5]

Right Ventricular Dysfunction

Right ventricular (RV) dysfunction is characterized by the presence of AT LEAST ONE of the following:[1][5]

Myocardial Necrosis

Myocardial necrosis is defined as the presence of:[1][5]

OR

Low-Risk Pulmonary Embolism

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 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.
  2. ↑ Piazza G, Goldhaber SZ (2011). "Chronic thromboembolic pulmonary hypertension". N Engl J Med. 364 (4): 351–60. doi:10.1056/NEJMra0910203. PMID 21268727.
  3. ↑ Hoeper MM, Madani MM, Nakanishi N, Meyer B, Cebotari S, Rubin LJ (2014). "Chronic thromboembolic pulmonary hypertension". Lancet Respir Med. doi:10.1016/S2213-2600(14)70089-X. PMID 24898750.
  4. ↑ 4.0 4.1 4.2 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute : the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
  5. ↑ 5.0 5.1 5.2 5.3 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. ↑ Ribeiro A, Lindmarker P, Johnsson H, Juhlin-Dannfelt A, Jorfeldt L (1999). "Pulmonary embolism: one-year follow-up with echocardiography doppler and five-year survival analysis". Circulation. 99 (10): 1325–30. PMID 10077516. Retrieved 2011-12-21. Unknown parameter |month= ignored (help)
  7. ↑ Fengler BT, Brady WJ (2009). "Fibrinolytic therapy in pulmonary embolism: an evidence-based treatment algorithm". Am J Emerg Med. 27 (1): 84–95. doi:10.1016/j.ajem.2007.10.021. PMID 19041539. Retrieved 2011-12-21. Unknown parameter |month= ignored (help)

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