Pulmonary embolism classification: Difference between revisions

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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}}
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==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).  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>
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 Based on Acuity and Size ==
==Classification Based on Acuity==
 
=== 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 PE]] or [[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:


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


=== Chronic Pulmonary Embolism ===
===Chronic Pulmonary Embolism===
PE is classified as chronic if it meets any of the following criteria:
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:''' A markedly progressive development of [[dyspnea]] over time, generally as a result of [[pulmonary hypertension]].
*'''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.
**Embolus reduces the arterial diameter by ≥ 50%.
**Evidence of recanalization within the thrombus.
**Presence of an arterial web.


==Classification Based on Disease Severity ==
==Classification Based on Disease Severity ==
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[[Pulmonary embolism classification#Right Ventricular Dysfunction|Right ventricular dysfunction]] OR [[Pulmonary embolism classification#Myocardial Necrosis|myocardial necrosis]]<br>
[[Pulmonary embolism classification#Right Ventricular Dysfunction|Right ventricular dysfunction]] OR [[Pulmonary embolism classification#Myocardial Necrosis|myocardial necrosis]]<br>
''AND'' <br>
''AND'' <br>
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>
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>
* 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.
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====Myocardial Necrosis====
====Myocardial Necrosis====
[[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>
[[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 ====
* A saddle PE is classified as an embolus that lodges at the bifurcation of the main [[pulmonary artery]] into the right and left pulmonary arteries.
* A saddle PE IS typically classified as submassive.


=== Low-Risk Pulmonary Embolism ===
=== Low-Risk Pulmonary Embolism ===
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[[Category:Hematology]]
[[Category:Hematology]]
[[Category:Pulmonology]]
[[Category:Pulmonology]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
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[[Category:Intensive care medicine]]
[[Category:Primary care]]

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Risk calculators and risk factors for Pulmonary embolism classification

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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