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Questions and Answers
What is the diagnosis of submassive PE based on?
What is the cutoff value for troponin I in diagnosing myocardial necrosis in PE?
Which of the following is a risk factor for VTE in hospitalized patients?
What is the definition of low-risk PE?
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What is the cutoff value for N-terminal pro-BNP in diagnosing RV dysfunction in PE?
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Which of the following is a risk factor for VTE in surgical inpatients?
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What is the next step in diagnosis if a D-dimer test result is positive?
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What is McConnell's sign?
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What is the primary goal of risk stratification in patients with acute pulmonary embolism?
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What is hemodynamic instability in the context of pulmonary embolism?
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What is the Hampton hump sign?
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What is the primary indication for performing a D-dimer test?
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What is the suggested treatment for patients with acute hypotensive PE with high bleeding risk or failed systemic thrombolysis?
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What is the FDA-approved regimen for alteplase in high-risk PE?
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Which of the following is an absolute contraindication to thrombolysis?
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What is the loading dose of streptokinase in FDA-approved regimen for PE?
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Which of the following is a relative contraindication to thrombolysis?
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What is the dose of urokinase in FDA-approved regimen for PE?
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Study Notes
D-Dimer Testing
- Not recommended if clinical suspicion is high, as a normal result does not exclude PE in patients with high predicted probability, even with high-sensitivity assays
- Positive result: perform diagnostic imaging
- Negative result: do not perform diagnostic imaging (PE may be excluded)
Diagnosis
- McConnell's sign: a distinct echocardiographic feature of acute massive PE, characterized by RV free wall akinesis with sparing of the apex
- Hampton hump sign: a dome-shaped area of opacification in the periphery of the left lower lobe, indicating PE
- CT angiogram: demonstrates multiple pulmonary artery filling defects, consistent with pulmonary emboli
Risk Stratification
- Assess all patients with acute PE for severity and risk of early death to determine management strategy
- Initially stratify patients by presence of hemodynamic instability to identify those at high risk of early death
- Hemodynamic instability definitions include:
- Cardiac arrest: need for CPR
- Obstructive shock: SBP < 90 mm Hg or vasopressors required to achieve blood pressure ≥ 90 mm Hg despite adequate filling status, with end-organ hypoperfusion
Management
- Catheter-directed thrombolysis: suggested in patients with acute hypotensive PE in case of high bleeding risk, failed systemic thrombolysis, and/or shock likely to result in death before systemic thrombolysis takes effect
- Surgical pulmonary embolectomy: suggested as an alternative to systemic thrombolysis if contraindicated or failed
High-Risk (Massive PE) Management
- Clot-specific lyrics and dosing regimens:
- Alteplase: 100 mg over 2 hours (FDA-approved)
- Urokinase: 4,400 units/kg over 10 minutes (FDA-approved)
- Streptokinase (no longer on market in US): 250,000 units loading dose over 30 minutes (FDA-approved)
- Absolute contraindications:
- Structural intracranial disease
- Previous intracranial hemorrhage
- Previous hemorrhagic stroke or stroke of unknown origin
- Ischemic stroke within 3 months
- Active bleeding or diathesis
- Recent intracranial or spinal surgery
- Recent lumbar puncture
- Major trauma, surgery, or head injury within 3 weeks
- Known malignant intracranial neoplasm
- Suspected aortic dissection
- Relative contraindications:
- Refractory HTN
- History of chronic, severe, and poorly controlled HTN
- Recent extracranial or internal bleeding
- Recent major surgery
- Recent invasive procedure
- Ischemic stroke > 3 months prior
- Current anticoagulation therapy
- Traumatic cardiopulmonary resuscitation
- Pericarditis or pericardial fluid
- Diabetic retinopathy
- Pregnancy
- Noncompressible vascular puncture site
- Dementia
- Age > 75 years old, low body weight, female, black race
- Active peptic ulcer, advanced hepatic disease, infective endocarditis
Submassive PE
- Defined as acute PE without systemic hypotension but with either RV dysfunction or myocardial necrosis
- RV dysfunction:
- RV dilation or RV systolic dysfunction on echocardiography
- Brain natriuretic peptide (BNP) > 90 pg/mL
- N-terminal pro-BNP > 500 pg/mL
- ECG changes
- Myocardial necrosis:
- Troponin I > 0.4 ng/mL or troponin T > 0.1 ng/mL
Low-Risk PE
- Defined as acute PE without clinical markers of adverse prognosis that define massive or submassive PE
Risk Factors
- In surgical inpatients:
- Pregnancy or postpartum
- Recent sepsis
- Malignancy
- Prior VTE
- Central venous access
- In hospitalized patients:
- Prior VTE
- Thrombophilia
- Surgery
- Cancer
- Pregnancy
- Immobilization
- Trauma
- Central venous access
- Medical illnesses:
- Cancer
- Prior VTE
- Inflammatory disease
- Infections
- Autoimmune disorders (IBD, SLE, and RA)
- Medications:
- Hormonal contraceptives
- Hormonal replacement therapy (HRT)
- Antipsychotics
- Fibrates
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Description
Identify the different categories of pulmonary embolism, including massive, submassive, and low-risk PE, and understand the clinical markers that define each category. Learn about the diagnosis and risk factors of PE.
