A 63-year-old man arrives in the emergency department with acute shortness of breath. His past medical history is remarkable for well-controlled hypertension. On admission, his heart rate is 113 bpm, oxygen saturation is 91%, and respiratory rate is 35 breaths/min. His blood pressure is 145/65 mm Hg. He underwent knee replacement surgery 15 days earlier. His physical examination is unremarkable, as are an electrocardiogram and chest radiograph. Computed tomography pulmonary angiography of the chest demonstrates large thrombi in the right and left main pulmonary arteries, extending into the lobar branches. His right-to-left ventricular ratio is markedly increased at 1.2, and troponin is elevated. Echocardiography performed at the bedside reveals moderate right ventricular hypokinesis and dilation. He is started on intravenous heparin and admitted to the intensive care unit.
EPIDEMIOLOGY OF PULMONARY EMBOLISM
Incidence of 300,000 to 600,000 events per year in the United States.1
Third leading cause of cardiovascular mortality after myocardial infarction and stroke.2
Overall in-hospital mortality of 4%.3
Most deaths that occur within 4 days of admission are attributable to the pulmonary embolism (PE).
Approximately half of deaths within 3 months of a PE are attributable to the PE, whereas the rest of the deaths most commonly occur due to cancer or underlying cardiopulmonary disease.
Approximately 25% to 35% of PEs present in the massive or submassive category.
Massive PE mortality ranges from 25% to 65%.4
Submassive PE mortality is 2% to 3%.5
Submassive PE clinical deterioration (progression to massive physiology and/or shock) of 5% to 6%.6,7
Low-risk PE mortality is <1%.4
CLASSIFICATION AND TERMINOLOGY
For classification and terminology of PE, see Tables 29-1 and 29-2.4,8,9
Table 29-1Societal Guidelines Stratification Schemes |Favorite Table|Download (.pdf) Table 29-1 Societal Guidelines Stratification Schemes
|Clinical Presentation ||American Heart Association Classification4 ||European Society of Cardiology Classification8 |
|Hypotension (systolic blood pressure <90 mm="" hg="" for="" 15="" minutes,="" or="" requiring="" vasopressor="" support,="" or="">40-mm Hg drop in systolic blood pressure) ||Massive ||High risk |
| ||Submassive || |
Subclassified as high risk intermediate if echocardiography and computed tomography show right ventricular dysfunction and cardiac biomarkers are elevated
Subclassified as low risk intermediate if only 1 or neither of the above (imaging/biomarkers) is present
|No hypotension, right ventricular dysfunction ||Low risk ||Low risk |
Table 29-2.Simplified Pulmonary Embolism Score Index (sPESI) Scoring System (a score ≥1 associated with an 11% 30-day mortality)9 |Favorite Table|Download (.pdf) Table 29-2. Simplified Pulmonary Embolism Score Index (sPESI) Scoring System (a score ≥1 associated with an 11% 30-day mortality)9
|Parameter (each parameter ...|