Pulmonary embolism classification
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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:
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).
Classification Based on Acuity and Size
Acute Pulmonary Embolism
An acute PE can be either silent, symptomatic, or fatal. Acute PE are also classified as massive pulmonary embolism or submassive pulmonary embolism or low-risk pulmonary embolism.
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.
- Embolus Size Criteria:
Chronic Pulmonary Embolism
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.
- Embolus Size Criteria:[1]
- 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
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 Pulmonary Embolism
- Massive PE accounts for 5-10% of pulmonary emboli.
- Historical Classification: A massive pulmonary embolism was defined using the Miller Index of angiographic burden.[2] This is a retrospective diagnosis based upon the pulmonary angiogram.
- 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%.[3]
According to the American Heart Association, massive PE is characterized by the presence of:
- 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
OR
- Persistent profound bradycardia (heart rate < 40 bpm) plus findings of shock[4]
Submassive Pulmonary Embolism
- 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%.[3]
According to the American Heart Association, submassive PE is characterized by:
AND
- Absence of systemic hypotension (systolic blood pressure >90 mm Hg)[5] [4]
- Submassive pulmonary embolism 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 pulmonary embolism 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:[4][5]
- Echocardiography findings:
- RV dilation (ratio of apical 4-chamber RV diameter to 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 T-wave inversion
Myocardial Necrosis
Myocardial necrosisis defined as the presence of:[4][5]
- Elevation of troponin I (>0.4 ng/mL)
OR
- Elevation of troponin T (>0.1 ng/mL)
Saddle 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 patients have a risk of PE-related early mortality of <1%.[3] According to the American Heart Association, low risk PE is characterized by the absence of hypotension, shock, RV dysfunction and myocardial necrosis.[4]
References
- ↑ Castañer E, Gallardo X, Ballesteros E, Andreu M, Pallardó Y, Mata JM; et al. (2009). "CT diagnosis of chronic pulmonary thromboembolism". Radiographics. 29 (1): 31–50, discussion 50-3. PMID doi=10.1148/rg.291085061 19168835 doi=10.1148/rg.291085061 Check
|pmid=value (help). - ↑ Miller GA, Sutton GC, Kerr IH, Gibson RV, Honey M (1971). "Comparison of streptokinase and heparin in treatment of isolated acute massive pulmonary embolism". Br Heart J. 33 (4): 616. PMID 5557502.
- ↑ 3.0 3.1 3.2 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (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)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
- ↑ 4.0 4.1 4.2 4.3 4.4 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 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) - ↑ 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) - ↑ 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)