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}} | ||
==Overview== | ==Overview== | ||
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> | |||
==Echocardiography== | ==Echocardiography== | ||
In massive and submassive PE, | * 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> | ||
Echocardiography | *[[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]] | * 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 | * 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> | ||
Shown below is an echocardiogram that demonstrates McConnell sign: | |||
{{#ev:youtube|Tklaxe-kPrk}} | |||
In addition | * 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}} | ||
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[[Category:Hematology]] | [[Category:Hematology]] | ||
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[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Intensive care medicine]] | |||
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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
- 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.[3]
- Echocardiography findings that are indicative of RV dysfunction are mainly:[4][5]
- RV dilation (ratio of apical 4-chamber RV diameter to left ventricle (LV) diameter > 0.9)
- RV systolic dysfunction
- Other echocardiographic findings that are supportive of the presence of RV dysfunction include:[1]
- Paradoxical 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)
- 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}}
- In addition, echocardiography findings that are associated with worse prognosis include:
- RV dysfunction[3]
- Right heart thrombus[7]
- Patent foramen ovale[8]
- Echocardiography should be used to confirm the presence of RV dysfunction if multidetector CT is not available.
References
- ↑ 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.
- ↑ 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.
- ↑ 3.0 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.
- ↑ 4.0 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.
- ↑ 5.0 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) - ↑ 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.
- ↑ 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.
- ↑ 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)