Pulmonary embolism classification: Difference between revisions

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__NOTOC__
__NOTOC__
{| class="infobox" style="float:right;"
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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''']]
|}
{{Pulmonary embolism}}
{{Pulmonary embolism}}
'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; {{AE}}
{{CMG}} {{ATI}}; {{AE}} {{Rim}}


==Overview==
==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).
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>


== Classification ==
==Classification Based on Acuity==
=== Classification Based on Acuity and Size ===


==== Acute Pulmonary Embolism ====
===Acute Pulmonary Embolism===
An acute PE can be either silent, symptomatic, or fatal.  Acute PE are also classified as [[Pulmonary embolism classification#Massive PE|massive pulmonary embolism]] or [[Pulmonary embolism classification#Submassive PE|submassive pulmonary embolism]] or [[Pulmonary embolism classification#Low-risk PE|low-risk 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]].


A PE is classified as acute if it meets any of the following criteria:
===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>


*'''Time Criterion:''' Symptom onset and physical sign presentation occur immediately after obstruction of pulmonary vessels.
==Classification Based on Disease Severity ==
*'''Embolus Size Criteria:'''
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).
**[[Embolus]] is located centrally within the vascular lumen.
**[[Embolus]] occludes a [[vessel]].
**[[Embolus]] causes distention of the involved vessel.


==== Chronic Pulmonary Embolism ====
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
A pulmonary embolism is classified as chronic if it meets any of the following criteria:
|-
*'''Time Criterion:''' A markedly progressive development of [[dyspnea]] over time, generally as a result of [[pulmonary hypertension]].
| 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>
*'''Embolus Size Criteria:'''<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>
|-
**Embolus is eccentric and contiguous with the vessel wall.
|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>
**Embolus reduces the arterial diameter by ≥ 50%.
OR<br>
**Evidence of recanalization within the thrombus.
- [[PEA|Pulselessness]]<br>
**Presence of an arterial web.
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]]
|-
|}


=== Classification Based on Disease Severity ===
=== Massive Pulmonary Embolism ===
In addition to the time of presentation and the size of the embolus, a pulmonary embolism 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).
* 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>


==== Massive Pulmonary Embolism ====
* According to the [[American Heart Association]], massive PE is characterized by the presence of:
* Massive PE accounts for 5-10% of pulmonary emboli.
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>
*'''Historical Classification:''' A massive pulmonary embolism was defined using the Miller Index of angiographic burden.<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]].
''OR''<br>
*'''Contemporary Classification:''' Massive pulmonary embolism 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 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>  Massive PE is characterized by the presence of:
[[PEA|Pulselessness]]<br>
*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 inotropic support
''OR''<br>
OR<br>
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>
*[[PEA|Pulselessness]]
OR<br>
*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>


==== Submassive Pulmonary Embolism ====
=== Submassive Pulmonary Embolism ===
* Submassive PE accounts for 20-25% of pulmonary emboli.
* Submassive PE accounts for 20-25% of pulmonary emboli.


* Submassive pulmonary embolism 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> According to the [[American Heart Association]], submassive PE is characterized by:
* 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>  
* [[Right ventricular dysfunction]] OR [[myocardial necrosis]]
 
AND <br>
* According to the [[American Heart Association]], submassive PE is characterized by:
* Absence of [[hypotension|systemic hypotension]] (systolic blood pressure >90 mm Hg)<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> <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>
 
* Submassive pulmonary embolism 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>
[[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)<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 significantly higher rate of in-hospital complications.
** A higher potential for long-term [[pulmonary hypertension]] and cardiopulmonary disease.
** 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 pulmonary embolism 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>
* 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>


====Right Ventricular Dysfunction====
====Right Ventricular Dysfunction====
[[Right ventricular dysfunction|Right ventricular (RV) dysfunction]] is characterized by the presence of AT LEAST ONE of the following:<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> <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>
[[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:
*[[Echocardiography]] findings:
** [[RV]] dilation (ratio of apical 4-chamber [[RV]] diameter to [[LV|left ventricle (LV)]] diameter > 0.9)  
** [[RV]] dilation (ratio of apical 4-chamber [[RV]] diameter to [[LV|left ventricle (LV)]] diameter > 0.9)  
Line 69: Line 81:


====Myocardial Necrosis====
====Myocardial Necrosis====
[[Myocardial necrosis]]is defined as the presence of:<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> <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>
[[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)
*Elevation of [[troponin I]] (>0.4 ng/mL)
OR <br>
''OR'' <br>
*Elevation of [[troponin T]] (>0.1 ng/mL)
*Elevation of [[troponin T]] (>0.1 ng/mL)


===== Saddle Pulmonary Embolism =====
=== Low-Risk Pulmonary Embolism ===
* A saddle pulmonary embolism is classified as an embolus that lodges at the bifurcation of the main [[pulmonary artery]] into the right and left pulmonary arteries.
* Saddle pulmonary embolisms are typically classified as submassive.
 
==== Low-Risk Pulmonary Embolism ====
* Low risk PE accounts for 70% of pulmonary emboli.
* 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]], [[RV dysfunction]] and [[myocardium|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>
* 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:Hematology]]
[[Category:Hematology]]
[[Category:Pulmonology]]
[[Category:Pulmonology]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]
[[Category:Primary care]]

Latest revision as of 23:53, 29 July 2020
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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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