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{{Pulmonary embolism}}
{{Pulmonary embolism}}
{{PE editors}}


{{PE editors}}
'''''Synonyms and Keywords:''''' PE


==Overview==
==Overview==
The symptoms of a pulmonary embolism depend upon the severity of the disease. Pulmonary embolism can be symptomatic or asymptomatic, and may even be diagnosed by imaging procedures performed for other diagnostic purposes.<ref name="pmid20592294">{{cite journal| author=Agnelli G, Becattini C| title=Acute pulmonary embolism. | journal=N Engl J Med | year= 2010 | volume= 363 | issue= 3 | pages= 266-74 | pmid=20592294 | doi=10.1056/NEJMra0907731 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20592294  }} </ref> The Prospective Investigation Of Pulmonary Embolism Diagnosis study ('''PIOPED''') found the following symptoms in 97% of patients with angiographic proven PE.<ref name="pmid17904458">{{cite journal| author=Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA et al.| title=Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. | journal=Am J Med | year= 2007 | volume= 120 | issue= 10 | pages= 871-9 | pmid=17904458 | doi=10.1016/j.amjmed.2007.03.024 | pmc=PMC2071924 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17904458  }} </ref>
The symptoms of a pulmonary embolism depend on the severity of the disease. Majority of the patients may remain asymptomatic and pulmonary embolism may be an incidental finding.<ref name="pmid20592294">{{cite journal |author=Agnelli G, Becattini C |title=Acute pulmonary embolism |journal=[[The New England Journal of Medicine]] |volume=363 |issue=3 |pages=266–74 |year=2010 |month=July |pmid=20592294 |doi=10.1056/NEJMra0907731 |url=http://www.nejm.org/doi/abs/10.1056/NEJMra0907731?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-26}}</ref> However, the common symptoms of pulmonary embolism range from mild [[dyspnea]], [[chest pain|pleuritic chest pain]], [[tachypnea]] to severe circulatory collapse and sustained [[hypotension]].<ref name="pmid17904458">{{cite journal |author=Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, Hull RD, Leeper KV, Sostman HD, Tapson VF, Buckley JD, Gottschalk A, Goodman LR, Wakefied TW, Woodard PK |title=Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II |journal=[[The American Journal of Medicine]] |volume=120 |issue=10 |pages=871–9 |year=2007 |month=October |pmid=17904458 |pmc=2071924 |doi=10.1016/j.amjmed.2007.03.024 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(07)00463-9 |accessdate=2012-04-26}}</ref><ref name="pmid20592294">{{cite journal |author=Agnelli G, Becattini C |title=Acute pulmonary embolism |journal=[[The New England Journal of Medicine]] |volume=363 |issue=3 |pages=266–74 |year=2010 |month=July |pmid=20592294 |doi=10.1056/NEJMra0907731 |url=http://www.nejm.org/doi/abs/10.1056/NEJMra0907731?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-26}}</ref> The absence of these symptoms may be associated with reduced clinical probability of pulmonary embolism. Additionally, the [[Deep vein thrombosis history and symptoms|symptoms]] of lower extremity [[Deep vein thrombosis history and symptoms|deep venous thrombosis]] may also be present.
 
==Common symptoms==
*[[Dyspnea]] with or without pleuritic [[chest pain]].
 
*[[Hemoptysis]] secondary to distal vessel embolism with subsequent [[pulmonary infarction]] ([[alveolar haemorrhage]]).<ref name="pmid9377961">{{cite journal |author=Stein PD, Henry JW |title=Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes |journal=[[Chest]] |volume=112 |issue=4 |pages=974–9 |year=1997 |month=October |pmid=9377961 |doi= |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=9377961 |accessdate=2012-04-26}}</ref>
 
*Circulatory collapse with subsequent [[syncope]], sustained [[hypotension]] and [[shock]] which are associated with massive pulmonary embolism.<ref name="pmid21422387">{{cite journal |author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK |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]] |volume=123 |issue=16 |pages=1788–830 |year=2011 |month=April |pmid=21422387 |doi=10.1161/CIR.0b013e318214914f |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21422387 |accessdate=2012-04-26}}</ref><ref name="pmid20592294">{{cite journal |author=Agnelli G, Becattini C |title=Acute pulmonary embolism |journal=[[The New England Journal of Medicine]] |volume=363 |issue=3 |pages=266–74 |year=2010 |month=July |pmid=20592294 |doi=10.1056/NEJMra0907731 |url=http://www.nejm.org/doi/abs/10.1056/NEJMra0907731?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-26}}</ref>
 
*Among the elderly, symptoms of pulmonary embolism may mimic an indolent [[pneumonia]] or [[heart failure]].
 
==Supportive trial data==
The '''''Prospective Investigation Of Pulmonary Embolism Diagnosis (PIOPED) study''''' identified the following symptoms to be present in majority of with angiographically proven pulmonary embolism.<ref name="pmid17904458">{{cite journal| author=Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA et al.| title=Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. | journal=Am J Med | year= 2007 | volume= 120 | issue= 10 | pages= 871-9 | pmid=17904458 | doi=10.1016/j.amjmed.2007.03.024 | pmc=PMC2071924 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17904458  }} </ref>
*[[Dyspnea]]
*[[Dyspnea]]
*Pleuritic chest pain
*[[Chest pain|Pleuritic chest pain]]
*[[Tachypnea]]
*[[Tachypnea]]
The absence of this triad reduces the clinical probability of PE. Symptoms or signs of lower extremity [[Deep vein thrombosis history and symptoms|deep venous thrombosis]] (DVT) can also be present in the patient.
==History & Symptoms==
Three major clinical presentations can exist:
#[[Dyspnea]] with or without pleuritic [[chest pain]] (most frequent presentations of PE) and [[hemoptysis]]
#Hemodynamic instability and [[syncope]] (associated with massive pulmonary embolism)
#In the elderly, it may mimick as indolent [[pneumonia]] or [[heart failure]].
Emboli in the distal vessel causes pleural irritation and produces chest pain, it appears like a pulmonary infarction (alveolar haemorrhage) and sometimes accompanied by haemoptysis<ref name="pmid9377961">{{cite journal| author=Stein PD, Henry JW| title=Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes. | journal=Chest | year= 1997 | volume= 112 | issue= 4 | pages= 974-9 | pmid=9377961 | doi= | pmc= | url= }} </ref>. [[Syncope]] is rare, but an important presentation of PE, since it may indicate a severely decreased haemodynamic reserve<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>. Thus, the symptoms are highly variable, nonspecific, and common among patients with and without PE.


Pulmonary embolism should be suspected in all patients who present with the following symptoms, without an alternative obvious cause<ref name="pmid20592294">{{cite journal| author=Agnelli G, Becattini C| title=Acute pulmonary embolism. | journal=N Engl J Med | year= 2010 | volume= 363 | issue= 3 | pages= 266-74 | pmid=20592294 | doi=10.1056/NEJMra0907731|pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20592294  }} </ref>.
==ESC Guideline Recommendation- Suspected High-risk PE<ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP |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=[[European Heart Journal]] |volume=29 |issue=18 |pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18757870 |accessdate=2012-04-26}}</ref>==
* [[Dyspnea]] (new or worsening)
{{cquote|
* [[Chest pain]]
===[[European society of cardiology#Classes of Recommendations|Class I]]===
* Sustained [[Hypotension]]
'''1.''' In high-risk PE, as indicated by the presence of [[shock]] or [[hypotension]], emergency [[Pulmonary embolism diagnosis algorithm#CT equipped hospitals|CT]] or bedside [[Pulmonary embolism echocardiography|echocardiography]] (depending on availability and clinical circumstances) is recommended for diagnostic purposes. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''}}


However, the confirmed diagnosis is only possible in approximately 1/5th of the total patients.<ref name="pmid18424324">{{cite journal| author=Righini M, Le Gal G, Aujesky D, Roy PM, Sanchez O, Verschuren F et al.| title=Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. | journal=Lancet | year= 2008 | volume= 371 | issue= 9621 | pages= 1343-52 | pmid=18424324 | doi=10.1016/S0140-6736(08)60594-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18424324  }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18783189 Review in: ACP J Club. 2008 Sep 16;149(3):13] </ref> Furthermore the diagnostic workup should be changed depending upon the patient's clinical presentation and hemodynamic stability.
==Guideline Resources==
[http://eurheartj.oxfordjournals.org/content/29/18/2276.long 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]<ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP |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=[[European Heart Journal]] |volume=29 |issue=18 |pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18757870 |accessdate=2012-04-26}}</ref>  


==References==
==References==

Revision as of 20:21, 26 April 2012

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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: Cafer Zorkun, M.D., Ph.D. [2]

Synonyms and Keywords: PE

Overview

The symptoms of a pulmonary embolism depend on the severity of the disease. Majority of the patients may remain asymptomatic and pulmonary embolism may be an incidental finding.[1] However, the common symptoms of pulmonary embolism range from mild dyspnea, pleuritic chest pain, tachypnea to severe circulatory collapse and sustained hypotension.[2][1] The absence of these symptoms may be associated with reduced clinical probability of pulmonary embolism. Additionally, the symptoms of lower extremity deep venous thrombosis may also be present.

Common symptoms

Supportive trial data

The Prospective Investigation Of Pulmonary Embolism Diagnosis (PIOPED) study identified the following symptoms to be present in majority of with angiographically proven pulmonary embolism.[2]

ESC Guideline Recommendation- Suspected High-risk PE[5]

“

Class I

1. In high-risk PE, as indicated by the presence of shock or hypotension, emergency CT or bedside echocardiography (depending on availability and clinical circumstances) is recommended for diagnostic purposes. (Level of Evidence: C)

”

Guideline Resources

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[5]

References

  1. ↑ 1.0 1.1 1.2 Agnelli G, Becattini C (2010). "Acute pulmonary embolism". The New England Journal of Medicine. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, Hull RD, Leeper KV, Sostman HD, Tapson VF, Buckley JD, Gottschalk A, Goodman LR, Wakefied TW, Woodard PK (2007). "Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II". The American Journal of Medicine. 120 (10): 871–9. doi:10.1016/j.amjmed.2007.03.024. PMC 2071924. PMID 17904458. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
  3. ↑ Stein PD, Henry JW (1997). "Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes". Chest. 112 (4): 974–9. PMID 9377961. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
  4. ↑ Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK (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. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
  5. ↑ 5.0 5.1 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP (2008). "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)". European Heart Journal. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)

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