Pulmonary embolism classification
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editors-in-Chief: Ujjwal Rastogi, MBBS [2]
Synonyms and keywords: PE
Overview
Pulmonary embolism (PE) is classified in two different ways based upon:
- Time of appearance of symptoms & size of embolus : Acute vs Chronic
- Severity of the disease : Massive vs Submassive vs Low-risk (the incidence Massive, Submassive and Low-risk PE are 5%, 40% and 55% respectively).
Acute PE
Pulmonary embolism is called acute, if the embolism is
- Based on time of appearance of symptoms:
- Develop symptoms and signs immediately after obstruction of pulmonary vessels.
- Based on characteristic of the embolus:
- Situated centrally within the vascular lumen
- Occludes a vessel
- It also causes distention of the involved vessel.
Acute PE can be further classified as massive pulmonary embolism, submassive pulmonary embolism or low-risk pulmonary embolism.
Chronic PE
Chronic pulmonary embolism is a consequence of incomplete resolution of pulmonary embolism. It can be characterized:
- Based on time of appearance of symptoms:
- Develop slowly progressive dyspnea over a period of years due to pulmonary hypertension.
- Based on characteristic of the embolus:[1]
- Embolus is eccentric and contiguous with the vessel wall
- Embolus reducing the arterial diameter by ≥50%
- Evidence of recanalization within the thrombus
- Presence of an arterial web
Massive PE
In the past, massive pulmonary embolism has been defined on the basis of angiographic burden of emboli by using the Miller Index.[2] This is a retrospective diagnosis based upon the pulmonary angiogram that does not inform prospective decisions.
Recently the American Heart Association has proposed the following definition for massive PE: Acute pulmonary embolism with sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction), pulselessness, or persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock). [3]
Submassive PE
The American Heart Association has proposed the following definition for submassive PE: Acute PE without systemic hypotension (systolic blood pressure ≥90 mm Hg) but with either RV dysfunction or myocardial necrosis. [3]
Submassive PE patient population has the following characteristics:[4][5]
- Significantly higher rate of in-hospital complications.
- Have potential for long-term pulmonary hypertension and cardiopulmonary disease.
These patient, though hemodynamic stable and may initially appear to be clinically stable, but patient can undergo a cycle of progressive RV failure. Thus watchful waiting of such patients could lead to irreversible damage and death.[6]
Low-risk PE
The American Heart Association has proposed the following definition for Low-risk PE: Acute PE and the absence of the clinical markers of adverse prognosis that define massive or submassive PE.[3]
Saddle PE
A saddle PE is one that lodges at the bifurcation of the main pulmonary artery into the right and left pulmonary arteries. Most of the saddle PE are submassive.
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. doi:10.1148/rg.291085061. PMID 19168835.
- ↑ 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 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.
- ↑ 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) - ↑ 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)