|
|
| Line 126: |
Line 126: |
| {{main|Thrombolysis}} | | {{main|Thrombolysis}} |
|
| |
|
| Massive PE causing hemodynamic instability (shock and/or hypotension, defined as a systolic blood pressure <90 mmHg or a pressure drop of 40 mmHg for>15 min if not caused by new-onset arrhythmia, hypovolemia or sepsis) is an indication for [[thrombolysis]], the enzymatic destruction of the clot with medication. It is the best available medical treatment in this situation and is supported by clinical guidelines.<ref>{{cite journal |author= |title=British Thoracic Society guidelines for the management of suspected acute pulmonary embolism |journal=Thorax |volume=58 |issue=6 |pages=470–83 |year=2003 |month=June |pmid=12775856 |pmc=1746692 |doi=10.1136/thorax.58.6.470 |url=http://thorax.bmj.com/cgi/content/full/58/6/470 |last1= British Thoracic Society Standards Of Care Committee Pulmonary Embolism Guideline Development |first1= Group}}</ref><ref name=ESC>{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, ''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. |volume=29 |issue=18 |pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310 |last12=Mayer |first12=E |last13=Remy-Jardin |first13=M |last14=Bassand |first14=JP |last15=Vahanian |first15=A |last16=Camm |first16=J |last17=De Caterina |first17=R |last18=Dean |first18=V |last19=Dickstein |first19=K |last20=Filippatos |first20=G |last21=Funck-Brentano |first21=C |last22=Hellemans |first22=I |last23=Kristensen |first23=SD |last24=Mcgregor |first24=K |last25=Sechtem |first25=U |last26=Silber |first26=S |last27=Tendera |first27=M |last28=Widimsky |first28=P |last29=Zamorano |first29=JL |last30=Zamorano |first30=JL |last31=Andreotti |first31=F |last32=Ascherman |first32=M |last33=Athanassopoulos |first33=G |last34=De Sutter |first34=J |last35=Fitzmaurice |first35=D |last36=Forster |first36=T |last37=Heras |first37=M |last38=Jondeau |first38=G |last39=Kjeldsen |first39=K |last40=Knuuti |first40=J |last41=Lang |first41=I |last42=Lenzen |first42=M |last43=Lopez-Sendon |first43=J |last44=Nihoyannopoulos |first44=P |last45=Perez Isla |first45=L |last46=Schwehr |first46=U |last47=Torraca |first47=L |last48=Vachiery |first48=JL |last49=Task Force For The Diagnosis And Management Of Acute Pulmonary Embolism Of The European Society Of |first49=Cardiology}}</ref><ref>{{cite journal |author=Hirsh J, Guyatt G, Albers GW, Harrington R, Schünemann HJ |title=Executive summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) |journal=Chest |volume=133 |issue=6 Suppl |pages=71S–109S |year=2008 |month=June |pmid=18574259 |doi=10.1378/chest.08-0693 |url=http://www.chestjournal.org/lookup/pmid?view=long&pmid=18574259}}</ref> | | Massive PE causing hemodynamic instability (shock and/or hypotension, defined as a systolic blood pressure <90 mmHg or a pressure drop of 40 mmHg for>15 min if not caused by new-onset arrhythmia, hypovolemia or sepsis) is an indication for [[thrombolysis]], the enzymatic destruction of the clot with medication. It is the best available medical treatment in this situation and is supported by clinical guidelines. <cite>REFNAME33</cite> <cite>ESC</cite> <cite>REFNAME34</cite> |
|
| |
|
| The use of thrombolysis in non-massive PEs is still debated. The aim of the therapy is to dissolve the clot, but there is an attendant risk of bleeding or [[cerebrovascular accident|stroke]].<ref>{{cite journal |author=Dong B, Jirong Y, Liu G, Wang Q, Wu T |title=Thrombolytic therapy for pulmonary embolism |journal=Cochrane Database Syst Rev |issue=2 |pages=CD004437 |year=2006 |pmid=16625603 |doi=10.1002/14651858.CD004437.pub2 |editor1-last=Dong |editor1-first=Bi Rong }}</ref> The main indication for thrombolysis is in submassive PE where right ventricular dysfunction can be demonstrated on [[echocardiography]], and the presence of visible thrombus in the atrium.<ref>{{cite journal | author=Goldhaber SZ | title=Pulmonary embolism |journal=Lancet | year=2004 | volume=363 | pages=1295–305 | pmid=15094276 | doi=10.1016/S0140-6736(04)16004-2 | issue=9417}}</ref> | | The use of thrombolysis in non-massive PEs is still debated. The aim of the therapy is to dissolve the clot, but there is an attendant risk of bleeding or [[cerebrovascular accident|stroke]]. <cite>REFNAME35</cite> The main indication for thrombolysis is in submassive PE where right ventricular dysfunction can be demonstrated on [[echocardiography]], and the presence of visible thrombus in the atrium. <cite>REFNAME36</cite> |
|
| |
|
| ===Surgery=== | | ===Surgery=== |
| [[File:Inferior vena cava filter.jpg|thumb|right|Used inferior vena cava filter.]] | | [[File:Inferior vena cava filter.jpg|thumb|right|Used inferior vena cava filter.]] |
| Surgical management of acute pulmonary embolism ([[pulmonary thrombectomy]]) is uncommon and has largely been abandoned because of poor long-term outcomes. However, recently, it has gone through a resurgence with the revision of the surgical technique and is thought to benefit selected patients.<ref>{{cite journal | author=Augustinos P, Ouriel K | title=Invasive approaches to treatment of venous thromboembolism | journal=Circulation | year=2004 | volume=110 | issue=9 Suppl 1 | pages=I27–34 | pmid=15339878 | doi=10.1161/01.CIR.0000140900.64198.f4}}</ref> | | Surgical management of acute pulmonary embolism ([[pulmonary thrombectomy]]) is uncommon and has largely been abandoned because of poor long-term outcomes. However, recently, it has gone through a resurgence with the revision of the surgical technique and is thought to benefit selected patients. <cite>REFNAME37</cite> |
|
| |
|
| Chronic pulmonary embolism leading to [[pulmonary hypertension]] (known as ''chronic thromboembolic hypertension'') is treated with a surgical procedure known as a [[pulmonary thromboendarterectomy]]. | | Chronic pulmonary embolism leading to [[pulmonary hypertension]] (known as ''chronic thromboembolic hypertension'') is treated with a surgical procedure known as a [[pulmonary thromboendarterectomy]]. |
| Line 138: |
Line 138: |
| ===Inferior vena cava filter=== | | ===Inferior vena cava filter=== |
| {{main|inferior vena cava filter}} | | {{main|inferior vena cava filter}} |
| If anticoagulant therapy is [[contraindication|contraindicated]] and/or ineffective, or to prevent new emboli from entering the pulmonary artery and combining with an existing blockage, an [[inferior vena cava filter]] may be implanted.<ref name=pmid9459643>{{cite journal |author=Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral F, Huet Y, Simonneau G |title=A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group |journal=N Engl J Med |volume=338 |issue=7 |pages=409–15 |year=1998 |pmid=9459643 |doi=10.1056/NEJM199802123380701 |last12=Simonneau |first12=G}}</ref> | | If anticoagulant therapy is [[contraindication|contraindicated]] and/or ineffective, or to prevent new emboli from entering the pulmonary artery and combining with an existing blockage, an [[inferior vena cava filter]] may be implanted. <cite>REFNAME38</cite> |
|
| |
|
| ==Prognosis== | | ==Prognosis== |
| [[File:Saddle thromboembolus.jpg|thumb|Large saddle embolus seen at PA.]] | | [[File:Saddle thromboembolus.jpg|thumb|Large saddle embolus seen at PA.]] |
| [[Mortality rate|Mortality]] from untreated PE is said to be 26%. This figure comes from a trial published in 1960 by Barrit and Jordan,<ref name=Barritt>{{cite journal|author=Barritt DW, Jordan SC | title=Anticoagulant drugs in the treatment of pulmonary embolism: a controlled trial | journal=[[The Lancet|Lancet]] | year=1960 | volume=1 | pages=1309–12 | pmid=13797091 | doi=10.1016/S0140-6736(60)92299-6|issue=7138 }}</ref> which compared anticoagulation against placebo for the management of PE. Barritt and Jordan performed their study in the [[Bristol Royal Infirmary]] in 1957. This study is the only placebo controlled trial ever to examine the place of anticoagulants in the treatment of PE, the results of which were so convincing that the trial has never been repeated as to do so would be considered unethical. That said, the reported mortality rate of 26% in the placebo group is probably an overstatement, given that the technology of the day may have detected only severe PEs. | | [[Mortality rate|Mortality]] from untreated PE is said to be 26%. This figure comes from a trial published in 1960 by Barrit and Jordan <cite>Barritt</cite>, which compared anticoagulation against placebo for the management of PE. Barritt and Jordan performed their study in the [[Bristol Royal Infirmary]] in 1957. This study is the only placebo controlled trial ever to examine the place of anticoagulants in the treatment of PE, the results of which were so convincing that the trial has never been repeated as to do so would be considered unethical. That said, the reported mortality rate of 26% in the placebo group is probably an overstatement, given that the technology of the day may have detected only severe PEs. |
|
| |
|
| Prognosis depends on the amount of lung that is affected and on the co-existence of other medical conditions; chronic embolisation to the lung can lead to [[pulmonary hypertension]]. After a massive PE, the embolus must be resolved somehow if the patient is to survive. In thrombotic PE, the blood clot may be broken down by [[fibrinolysis]], or it may be organized and recanalized so that a new channel forms through the clot. Blood flow is restored most rapidly in the first day or two after a PE.<ref>{{cite journal | journal = British Medical Journal | date=17 October 1970| volume = 4 | pages = 135–139 | doi = 10.1136/bmj.4.5728.135 | title = Resolution of Pulmonary Embolism | first1 = R. H. Secker | last1 = Walker | first2 = Judy A. | last2 = Jackson | first3 = Jan | last3 = Goodwin | pmid = 5475816 | issue = 5728 | pmc = 1819885}}</ref> Improvement slows thereafter and some deficits may be permanent. There is controversy over whether or not small subsegmental PEs need to be treated at all<ref>{{cite journal |author=Le Gal G, Righini M, Parent F, van Strijen M, Couturaud F |title=Diagnosis and management of subsegmental pulmonary embolism |journal=J Thromb Haemost |volume=4 |issue=4 |pages=724–31 |year=2006 |pmid=16634736 |doi=10.1111/j.1538-7836.2006.01819.x}}</ref> and some evidence exists that patients with subsegmental PEs may do well without treatment.<ref name=pmid16738268>{{cite journal |author=Stein P, Fowler S, Goodman L, Gottschalk A, Hales C, Hull R, Leeper K, Popovich J, Quinn D, Sos T, Sostman H, Tapson V, Wakefield T, Weg J, Woodard P |title=Multidetector computed tomography for acute pulmonary embolism |journal=N Engl J Med |volume=354 |issue=22 |pages=2317–27 |year=2006 |pmid=16738268 |doi=10.1056/NEJMoa052367 |last12=Tapson |first12=VF |last13=Wakefield |first13=TW |last14=Weg |first14=JG |last15=Woodard |first15=PK |last16=Pioped Ii |first16=Investigators}}</ref><ref name=pmid16738276>{{cite journal |author=Perrier A, Bounameaux H |title=Accuracy or outcome in suspected pulmonary embolism |journal=N Engl J Med |volume=354 |issue=22 |pages=2383–5 |year=2006 |pmid=16738276|url=http://content.nejm.org/cgi/content/full/354/22/2383 |doi=10.1056/NEJMe068076}}</ref> | | Prognosis depends on the amount of lung that is affected and on the co-existence of other medical conditions; chronic embolisation to the lung can lead to [[pulmonary hypertension]]. After a massive PE, the embolus must be resolved somehow if the patient is to survive. In thrombotic PE, the blood clot may be broken down by [[fibrinolysis]], or it may be organized and recanalized so that a new channel forms through the clot. Blood flow is restored most rapidly in the first day or two after a PE. <cite>REFNAME39</cite> Improvement slows thereafter and some deficits may be permanent. There is controversy over whether or not small subsegmental PEs need to be treated at all <cite>REFNAME40</cite> and some evidence exists that patients with subsegmental PEs may do well without treatment. <cite>REFNAME41</cite> <cite>REFNAME42</cite> |
|
| |
|
| Once anticoagulation is stopped, the risk of a fatal pulmonary embolism is 0.5% per year.<ref>{{cite journal |author=White RH |title=Risk of fatal pulmonary embolism was 0.49 per 100 person-years after discontinuing anticoagulant therapy for venous thromboembolism |journal=Evid Based Med |volume=13 |issue=5 |pages=154 |year=2008 |month=October |pmid=18836122 |doi=10.1136/ebm.13.5.154 |url=}}</ref> | | Once anticoagulation is stopped, the risk of a fatal pulmonary embolism is 0.5% per year. <cite>REFNAME43</cite> |
|
| |
|
| ===Predicting mortality=== | | ===Predicting mortality=== |
| The PESI and Geneva prediction rules can estimate mortality and so may guide selection of patients who can be considered for outpatient therapy.<ref name=pmid17625081>{{cite journal |author=Jiménez D, Yusen RD, Otero R, ''et al.'' |title=Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy |journal=Chest |volume=132 |issue=1 |pages=24–30 |year=2007 |pmid=17625081 |doi=10.1378/chest.06-2921}}</ref> | | The PESI and Geneva prediction rules can estimate mortality and so may guide selection of patients who can be considered for outpatient therapy. <cite>REFNAME44</cite> |
|
| |
|
| ===Underlying causes=== | | ===Underlying causes=== |