Pulmonary Embolism Classification
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Questions and Answers

What is the diagnosis of submassive PE based on?

  • Myocardial necrosis only
  • RV dilation or RV systolic dysfunction on echocardiography or myocardial necrosis (correct)
  • RV dilation or RV systolic dysfunction on echocardiography and myocardial necrosis
  • Systemic hypotension only

    • What is the cutoff value for troponin I in diagnosing myocardial necrosis in PE?

  • 0.5 ng/mL
  • 0.1 ng/mL
  • 1.0 ng/mL
  • 0.4 ng/mL (correct)

    • Which of the following is a risk factor for VTE in hospitalized patients?

  • Hormonal replacement therapy (HRT)
  • Central venous access
  • Inflammatory disease
  • All of the above (correct)

    • What is the definition of low-risk PE?

    <p>Acute PE without clinical markers of adverse prognosis</p> Signup and view all the answers

    What is the cutoff value for N-terminal pro-BNP in diagnosing RV dysfunction in PE?

    <p>500 pg/mL</p> Signup and view all the answers

    Which of the following is a risk factor for VTE in surgical inpatients?

    <p>All of the above</p> Signup and view all the answers

    What is the next step in diagnosis if a D-dimer test result is positive?

    <p>Perform diagnostic imaging</p> Signup and view all the answers

    What is McConnell's sign?

    <p>An echocardiographic feature of acute massive pulmonary embolism</p> Signup and view all the answers

    What is the primary goal of risk stratification in patients with acute pulmonary embolism?

    <p>To identify patients at high risk of early death</p> Signup and view all the answers

    What is hemodynamic instability in the context of pulmonary embolism?

    <p>A systolic blood pressure &lt; 90 mm Hg or the need for vasopressors</p> Signup and view all the answers

    What is the Hampton hump sign?

    <p>A dome-shaped area of opacification in the periphery of the left lower lobe</p> Signup and view all the answers

    What is the primary indication for performing a D-dimer test?

    <p>To rule out pulmonary embolism in patients with low clinical suspicion</p> Signup and view all the answers

    What is the suggested treatment for patients with acute hypotensive PE with high bleeding risk or failed systemic thrombolysis?

    <p>Catheter-directed thrombolysis</p> Signup and view all the answers

    What is the FDA-approved regimen for alteplase in high-risk PE?

    <p>100 mg over 2 hours</p> Signup and view all the answers

    Which of the following is an absolute contraindication to thrombolysis?

    <p>Structural intracranial disease</p> Signup and view all the answers

    What is the loading dose of streptokinase in FDA-approved regimen for PE?

    <p>250,000 units</p> Signup and view all the answers

    Which of the following is a relative contraindication to thrombolysis?

    <p>Recent intracranial or spinal surgery</p> Signup and view all the answers

    What is the dose of urokinase in FDA-approved regimen for PE?

    <p>4,400 units/kg over 10 minutes</p> Signup and view all the answers

    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.

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