Authors
Harikrishna D, MBBS, MD (Med), DNB (Cardio) MNAMS, Department of Gastroenterology, Amrita Institute of Medical Sciences – AIMS, Ponekkara P.O., Cochin, Kerala, India; Assistant Professor of Cardiology and Interventional Cardiologist, Pariyaram Medical College, Kannur, Kerala, India.
Abstract
Background: Pulmonary embolism (PE) is a critical health issue, contributing significantly to morbidity and mortality, with rates around 14%. Prompt and appropriate treatment can reduce mortality by approximately 25%. This review aims to summarize the current state-of-the-art in PE assessment and management to serve as a practical guide.
Assessment: PE diagnosis lacks a single 100% specific or sensitive test. Initial evaluation includes clinical history, physical exam, chest X-ray, ECG, and arterial blood gases to rule out other conditions. Risk factors are diverse, including immobility, age, and various medical conditions. Symptoms range from typical dyspnoea and chest pain to atypical presentations. Diagnostic tools like D-dimers (for exclusion), V/Q scans, and CT Pulmonary Angiography (CTPA) are crucial, though pulmonary angiography remains the gold standard. PE is classified by extent (massive, submassive, minor) and duration (acute, subacute, chronic), and risk stratification relies on scores like PESI and sPESI.
Management: Management involves three components: primary treatment for clot removal, secondary prevention of recurrence, and hemodynamic/respiratory support. Primary treatment includes medical thrombolysis with rt-PA, surgical embolectomy for contraindications or failures, and interventional cardiology procedures like suction embolectomy. Secondary prevention utilizes anticoagulants such as unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), fondaparinux, vitamin K antagonists, and novel oral anticoagulants (NOACs) like rivaroxaban and apixaban. Inferior vena caval filters are an option for high-risk patients with contraindications to anticoagulation. Hemodynamic support involves inotropes, vasopressors, inhaled nitric oxide, and fluid management, while respiratory support focuses on mechanical ventilation and oxygenation.
Conclusion: Effective PE management requires rapid identification, accurate risk stratification, and tailored thrombolytic or anticoagulation therapies. Given the diverse clinical scenarios and limitations in evidence, individualized management based on a thorough risk-benefit assessment of therapeutic modalities is paramount.