Pulmonary Embolism PDF - NEJM 2022

The n e w e ng l a n d j o u r na l of m e dic i n e Clinical Practice Caren G. Solomon, M.D., M.P.H., Editor Pulmonary Embolism Susan R. Kahn, M.D., and...

The n e w e ng l a n d j o u r na l of m e dic i n e Clinical Practice Caren G. Solomon, M.D., M.P.H., Editor Pulmonary Embolism Susan R. Kahn, M.D., and Kerstin de Wit, M.B., Ch.B., M.D.​​ This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence sup- porting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations. A 41-year-old man presents to the emergency department with a 3-week history of From Lady Davis Institute at Jewish Gen- breathlessness. He recently completed a course of antibiotic medication for pre- eral Hospital and the Department of Medicine, McGill University, Montreal sumed pneumonia. On the day of presentation, he awoke with dull pain on the right (S.R.K.), the Department of Emergency side of the back. His medical history is otherwise unremarkable. His heart rate is Medicine, Queen’s University, Kingston, 88 beats per minute, blood pressure 149/86 mm Hg, respiratory rate 18 breaths per ON (K.W.), and the Departments of Med- icine and Health Research Methods, Evi- minute, temperature 37°C, and oxygen saturation 95% while he is breathing ambient dence, and Impact, McMaster Universi- air. Auscultation of his chest reveals normal breath sounds and normal heart sounds. ty, Hamilton, ON (K.W.) — all in Canada. An examination of the legs is normal. His creatinine and troponin levels are within Dr. Kahn can be contacted at ­susan​.­kahn@​ ­mcgill​.­ca. normal limits, and a radiograph of the chest is normal. The physician’s implicit as- sessment is that the likelihood of pulmonary embolism is greater than 15%. The Drs. Kahn and de Wit contributed equally to this article. patient’s Wells score is 0 (on a scale of 0 to 12.5, with higher scores indicating a higher probability of pulmonary embolism), and the d-dimer level is 2560 ng per This article was updated on July 7, 2022, at NEJM.org. milliliter. How would you evaluate this patient for pulmonary embolism, and how would you manage this case? N Engl J Med 2022;387:45-57. DOI: 10.1056/NEJMcp2116489 Copyright © 2022 Massachusetts Medical Society. The Cl inic a l Probl em CME P ulmonary embolism occurs when embolic venous thrombi are at NEJM.org caught within the branching lung vasculature. These thrombi often develop within the leg or pelvic veins, and approximately half of all deep-vein throm- bi embolize to the lungs.1 The annual incidence of pulmonary embolism world- An audio version wide is approximately 1 in 1000 persons.2,3 Although almost 20% of patients who of this article are treated for pulmonary embolism dies within 90 days,2 pulmonary embolism is is available at not commonly the cause of death because it frequently coexists with other serious NEJM.org conditions, such as cancer, sepsis, or illness leading to hospitalization, or with other events, such as surgeries. The true mortality associated with undiagnosed pulmo- nary embolism is estimated to be less than 5%,4 but recovery from pulmonary em- bolism is associated with complications such as bleeding due to anticoagulant treatment,5 recurrent venous thromboembolism, chronic thromboembolic pulmonary hypertension,6 and long-term psychological distress.7 Approximately half the patients who receive a diagnosis of pulmonary embolism have functional and exercise limitations 1 year later (known as post–pulmonary-embolism syndrome),8 and the health-related quality of life for patients with a history of pulmonary embolism is diminished as compared with that of matched controls.9 Therefore, the timely diag- nosis and expert management of pulmonary embolism are important. n engl j med 387;1 nejm.org July 7, 2022 45 The New England Journal of Medicine Downloaded from nejm.org by Sebastian Torres on September 15, 2022. For personal use only. No other uses without permission. Copyright © 2022 Massachusetts Medical Society. All rights reserved.  The n e w e ng l a n d j o u r na l of m e dic i n e Key Clinical Points Pulmonary Embolism Pulmonary embolism is a common diagnosis and can be associated with recurrent venous thromboembolism, bleeding due to anticoagulant therapy, chronic thromboembolic pulmonary hypertension, and long-term psychological distress. A minority of patients who are evaluated for possible pulmonary embolism benefit from chest imaging (e.g., computed tomography). Initial treatment is guided by classification of the pulmonary embolism as high-risk, intermediate-risk, or low-risk. Most patients have low-risk pulmonary embolism, and their care can be managed at home with a direct oral anticoagulant. Patients with acute pulmonary embolism should receive anticoagulant therapy for at least 3 months. The decision to continue treatment indefinitely depends on whether the associated reduction in the risk of recurrent venous thromboembolism outweighs the increased risk of bleeding and should take into account patient preferences. Patients should be followed longitudinally after an acute pulmonary embolism to assess for dyspnea or functional limitation, which may indicate the development of post–pulmonary-embolism syndrome or chronic thromboembolic pulmonary hypertension. S t r ategie s a nd E v idence (CT),14 resulting in only 30 to 40% of patients with suspected pulmonary embolism subsequently un- Diagnostic Testing for Pulmonary Embolism dergoing diagnostic imaging.13 Perhaps the most challenging aspect of testing In cases in which physicians have an implicit for pulmonary embolism is knowing when to sense that their patient is very unlikely to have test.10 Common symptoms of pulmonary embo- pulmonary embolism (estimated likelihood, lism are fatigue, breathlessness, chest pain, diz-