Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pulmonary Embolism Clinical Presentation

  • Author: Daniel R Ouellette, MD, FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
 
Updated: Jun 22, 2016
 

History

The challenge in dealing with pulmonary embolism is that patients rarely display the classic presentation of this problem, that is, the abrupt onset of pleuritic chest pain, shortness of breath, and hypoxia. Studies of patients who died unexpectedly from pulmonary embolism have revealed that often these individuals complained of nagging symptoms for weeks before death. Forty percent of these patients had been seen by a physician in the weeks prior to their death.[7]

The following risk factors can be indications for the presence of pulmonary embolism:

  • Venous stasis
  • Hypercoagulable states
  • Immobilization
  • Surgery and trauma
  • Pregnancy
  • Oral contraceptives and estrogen replacement
  • Malignancy
  • Hereditary factors resulting in a hypercoagulable state
  • Acute medical illness
  • Drug abuse (intravenous [IV] drugs)
  • Drug-induced lupus anticoagulant
  • Hemolytic anemias
  • Heparin-associated thrombocytopenia
  • Homocystinemia
  • Homocystinuria
  • Hyperlipidemias
  • Phenothiazines
  • Thrombocytosis
  • Varicose veins
  • Venography
  • Venous pacemakers
  • Venous stasis
  • Warfarin (first few days of therapy)
  • Inflammatory bowel disease

The PIOPED II study listed the following indicators for pulmonary embolism:

  • Travel of 4 hours or more in the past month
  • Surgery within the last 3 months
  • Malignancy, especially lung cancer
  • Current or past history of thrombophlebitis
  • Trauma to the lower extremities and pelvis during the past 3 months
  • Smoking
  • Central venous instrumentation within the past 3 months
  • Stroke, paresis, or paralysis
  • Prior pulmonary embolism
  • Heart failure
  • Chronic obstructive pulmonary disease
Next

Physical Examination

Physical examination findings are quite variable in pulmonary embolism and, for convenience, may be grouped into 4 categories as follows:

  • Massive pulmonary embolism
  • Acute pulmonary infarction
  • Acute embolism without infarction
  • Multiple pulmonary emboli or thrombi

The presentation of pulmonary embolism may vary from sudden catastrophic hemodynamic collapse to gradually progressive dyspnea. (Prior poor cardiopulmonary status of the patient is an important factor leading to hemodynamic collapse.) Most patients with pulmonary embolism have no obvious symptoms at presentation. In contrast, patients with symptomatic DVT commonly have pulmonary embolism confirmed on diagnostic studies in the absence of pulmonary symptoms. Sickle cell disease often creates a diagnostic difficulty with regard to pulmonary embolism. A chest infection is often the presenting symptom.

Patients with pulmonary embolism may present with atypical symptoms. In such cases, strong suspicion of pulmonary embolism based on the presence of risk factors can lead to consideration of pulmonary embolism in the differential diagnosis. These symptoms include the following:

  • Seizures
  • Syncope
  • Abdominal pain
  • Fever
  • Productive cough
  • Wheezing
  • Decreasing level of consciousness
  • New onset of atrial fibrillation
  • Flank pain [1]
  • Delirium (in elderly patients) [2]

The diagnosis of pulmonary embolism should be sought actively in patients with respiratory symptoms unexplained by an alternative diagnosis. The symptoms of pulmonary embolism are nonspecific; therefore, a high index of suspicion is required, particularly when a patient has risk factors for the condition.

Acute respiratory consequences of pulmonary embolism include the following:

  • Increased alveolar dead space
  • Hypoxemia
  • Hyperventilation

In patients with recognized pulmonary embolism, the incidence of physical signs has been reported as follows:

  • Tachypnea (respiratory rate >16/min) - 96%
  • Rales - 58%
  • Accentuated second heart sound - 53%
  • Tachycardia (heart rate >100/min) - 44%
  • Fever (temperature >37.8°C) - 43%
  • Diaphoresis - 36%
  • S 3 or S 4 gallop - 34%
  • Clinical signs and symptoms suggesting thrombophlebitis - 32%
  • Lower extremity edema - 24%
  • Cardiac murmur - 23%
  • Cyanosis - 19%

The PIOPED study reported the following incidence of common symptoms of pulmonary embolism[35] :

  • Dyspnea (73%)
  • Pleuritic chest pain (66%)
  • Cough (37%)
  • Hemoptysis (13%)

Fever of less than 39°C may be present in 14% of patients; however, temperature higher than 39.5°C is not from pulmonary embolism. Chest wall tenderness upon palpation, without a history of trauma, may be the sole physical finding in rare cases.

Pleuritic chest pain without other symptoms or risk factors may be a presentation of pulmonary embolism. Pleuritic or respirophasic chest pain is a particularly worrisome symptom. Pleuritic chest pain is reported to occur in as many as 84% of patients with pulmonary emboli. Its presence suggests that the embolus is located more peripherally and thus may be smaller.

Pulmonary embolism has been diagnosed in 21% of young, active patients who come to emergency departments (EDs) complaining only of pleuritic chest pain. These patients usually lack any other classical signs, symptoms, or known risk factors for pulmonary thromboembolism. Such patients often are dismissed inappropriately with an inadequate workup and a nonspecific diagnosis, such as musculoskeletal chest pain or pleurisy.

Massive pulmonary embolism

Patients with massive pulmonary embolism are in shock. They have systemic hypotension, poor perfusion of the extremities, tachycardia, and tachypnea. In addition, patients appear weak, pale, sweaty, and oliguric and develop impaired mentation.

Signs of pulmonary hypertension, such as palpable impulse over the second left intercostal space, loud P2, right ventricular S3 gallop, and a systolic murmur louder on inspiration at left sternal border (tricuspid regurgitation), may be present.

Massive pulmonary embolism has been defined by hemodynamic parameters and evidence of myocardial injury rather than anatomic findings because the former is associated with adverse outcomes.[42] Although previous studies of CT scans in the diagnosis of pulmonary embolus suggested that central obstruction was not associated with adverse outcomes, a new multicenter study clarifies this observation. Vedovati et al found no association between central obstruction and death or clinical deterioration in 579 patients with pulmonary embolus.[43] However, when a subset of 516 patients who were hemodynamically stable was assessed, central localization of emboli was found to be an independent mortality risk factor while distal localization was inversely associated with adverse events. Thus, anatomic findings by CT scan may be important in assessing risk in hemodynamically stable patients with pulmonary embolus.

Acute pulmonary infarction

Approximately 10% of patients have peripheral occlusion of a pulmonary artery, causing parenchymal infarction. These patients present with acute onset of pleuritic chest pain, breathlessness, and hemoptysis. Although the chest pain may be clinically indistinguishable from ischemic myocardial pain, normal ECG findings and no response to nitroglycerin rules out myocardial pain. Patients with acute pulmonary infarction have decreased excursion of the involved hemithorax, palpable or audible pleural friction rub, and even localized tenderness. Signs of pleural effusion, such as dullness to percussion and diminished breath sounds, may be present.

Acute embolism without infarction

Patients with acute embolism without infarction have nonspecific physical signs that may easily be secondary to another disease process. Tachypnea and tachycardia frequently are detected, pleuritic pain sometimes may be present, crackles may be heard in the area of embolization, and local wheeze may be heard rarely.

Multiple pulmonary emboli or thrombi

Patients with pulmonary emboli and thrombi have physical signs of pulmonary hypertension and cor pulmonale. Patients may have elevated jugular venous pressure, right ventricular heave, palpable impulse in the left second intercostal space, right ventricular S3 gallop, systolic murmur over the left sternal border that is louder during inspiration, hepatomegaly, ascites, and dependent pitting edema. These findings are not specific for pulmonary embolism and require a high index of suspicion for pursuing appropriate diagnostic studies.

Pulmonary emboli in children

Many physical findings are typically less marked in children than they are in adults, presumably because children have greater hemodynamic reserve and, thus, are better able to tolerate the significant hemodynamic and pulmonary changes.

Because of the rarity of pulmonary emboli in children, these patients are probably underdiagnosed. For the same reason, much of the information pertaining to diagnosis and management of pulmonary embolism has been derived from adult practice.

Cough is present in approximately 50% of children with pulmonary emboli; tachypnea occurs with the same frequency. Hemoptysis is a feature in a minority of children with pulmonary emboli, occurring in about 30% of cases. Crackles are heard in a minority of cases.

Cyanosis and hypoxemia are not prominent features of pulmonary embolism. If present, cyanosis suggests a massive embolism leading to a marked ventilation-perfusion (V/Q) mismatch and systemic hypoxemia. Some case reports have described massive pediatric pulmonary embolism with normal saturation.

A pleural rub is often associated with pleuritic chest pain and indicates an embolism in a peripheral location in the pulmonary vasculature. Signs that indicate pulmonary hypertension and right ventricular failure include a loud pulmonary component of the second heart sound, right ventricular lift, distended neck veins, and hypotension. An increase in pulmonary artery pressure is reportedly not evident until at least 60% of the vascular bed has been occluded.

A gallop rhythm signifies ventricular failure, while peripheral edema is a sign of congestive heart failure. Various heart murmurs may be audible, including a tricuspid regurgitant murmur signifying pulmonary hypertension.

Fever is an unusual sign that is nonspecific, and diaphoresis is a manifestation of sympathetic arousal. Signs of other organ involvement in patients with sickle cell disease would be elicited, such as sequestration crisis, priapism, anemia, and stroke.

Previous
 
 
Contributor Information and Disclosures
Author

Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Chair of the Clinical Competency Committee, Pulmonary and Critical Care Fellowship Program, Senior Staff and Attending Physician, Division of Pulmonary and Critical Care Medicine, Henry Ford Health System; Chair, Guideline Oversight Committee, American College of Chest Physicians

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, Society of Critical Care Medicine, American Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Nader Kamangar, MD, FACP, FCCP, FCCM Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Pulmonary and Critical Care Medicine, Vice-Chair, Department of Medicine, Olive View-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: Academy of Persian Physicians, American Academy of Sleep Medicine, American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, Association of Pulmonary and Critical Care Medicine Program Directors, Association of Specialty Professors, California Sleep Society, California Thoracic Society, Clerkship Directors in Internal Medicine, Society of Critical Care Medicine, Trudeau Society of Los Angeles, World Association for Bronchology and Interventional Pulmonology

Disclosure: Nothing to disclose.

Annie Harrington, MD Fellow in Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center

Annie Harrington, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Acknowledgements

Judith K Amorosa, MD, FACR Clinical Professor and Program Director, Department of Radiology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School; Consulting Staff, Department of Radiology, Robert Wood Johnson University Hospital

Judith K Amorosa, MD, FACR is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, and Society of Thoracic Radiology

Disclosure: Nothing to disclose.

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Kavita Garg, MD Professor, Department of Radiology, University of Colorado School of Medicine

Kavita Garg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, and Society of Thoracic Radiology

Disclosure: Nothing to disclose.

Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine

Disclosure: Nothing to disclose.

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

Eric J Stern, MD Professor of Radiology, Adjunct Professor of Medicine, Adjunct Professor of Medical Education and Biomedical Informatics, Adjunct Professor of Global Health, Vice-Chair, Academic Affairs, University of Washington School of Medicine

Eric J Stern, MD is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, European Society of Radiology, Radiological Society of North America, and Society of Thoracic Radiology

Disclosure: Nothing to disclose.

Sara F Sutherland, MD, MBA, FACEP Assistant Professor of Emergency Medicine, University of Virginia Health System; Staff Physician, Department of Emergency Medicine, Martha Jefferson Hospital

Sara F Sutherland, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gregory Tino, MD Director of Pulmonary Outpatient Practices, Associate Professor, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Medical Center and Hospital

Gregory Tino, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

References
  1. Amesquita M, Cocchi MN, Donnino MW. Pulmonary Embolism Presenting as Flank Pain: A Case Series. J Emerg Med. 2009 Mar 26. [Medline].

  2. Carrascosa MF, Batán AM, Novo MF. Delirium and pulmonary embolism in the elderly. Mayo Clin Proc. 2009. 84(1):91-2. [Medline]. [Full Text].

  3. Tapson VF. Acute pulmonary embolism. N Engl J Med. 2008 Mar 6. 358(10):1037-52. [Medline].

  4. [Guideline] Qaseem A, Snow V, Barry P, Hornbake ER, Rodnick JE, Tobolic T, et al. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med. 2007 Jan-Feb. 5 (1):57-62. [Medline]. [Full Text].

  5. [Guideline] Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb. 141 (2 Suppl):7S-47S. [Medline].

  6. Ozsu S, Oztuna F, Bulbul Y, et al. The role of risk factors in delayed diagnosis of pulmonary embolism. Am J Emerg Med. 2011 Jan. 29(1):26-32. [Medline].

  7. Kline JA, Runyon MS. Pulmonary embolism and deep venous thrombosis. In: Marx JA, Hockenberger RS, Walls RM, eds. Rosen's Emergency Medicine Concepts and Clinical Practice. 6th ed. 1368-1382. Vol 2.:

  8. Boyden EA. Segmental Anatomy of the Lungs: Study of the Patterns of the Segmental Bronchi and Related Pulmonary Vessels. New York, NY: McGraw-Hill; 1955:. 23-32.

  9. Mitchell RN, Kumar V. Hemodynamic disorders, thrombosis, and shock. In: Kumar V, Cotran RS, Robbins SL, eds. Basic Pathology. 6th ed. Philadelphia, Pa: WB Saunders; 1997:. 60-80.

  10. Wharton LR, Pierson JW. JAMA. Minor forms of pulmonary embolism after abdominal operations.

  11. Malek J, Rogers R, Kufera J, Hirshon JM. Venous thromboembolic disease in the HIV-infected patient. Am J Emerg Med. 2011 Mar. 29(3):278-82. [Medline].

  12. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994 Dec 15. 331(24):1601-6. [Medline].

  13. van den Heuvel-Eibrink MM, Lankhorst B, Egeler RM, Corel LJ, Kollen WJ. Sudden death due to pulmonary embolism as presenting symptom of renal tumors. Pediatr Blood Cancer. 2008 May. 50(5):1062-4. [Medline].

  14. Arzt M, Luigart R, Schum C, Lüthje L, Stein A, Koper I, et al. Sleep-disordered breathing in deep vein thrombosis and acute pulmonary embolism. Eur Respir J. 2012 Oct. 40(4):919-24. [Medline].

  15. Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007 Oct. 120(10):871-9. [Medline]. [Full Text].

  16. David M, Andrew M. Venous thromboembolic complications in children. J Pediatr. 1993 Sep. 123(3):337-46. [Medline].

  17. Biss TT, Brandão LR, Kahr WH, Chan AK, Williams S. Clinical features and outcome of pulmonary embolism in children. Br J Haematol. 2008 Sep. 142(5):808-18. [Medline].

  18. Nuss R, Hays T, Chudgar U, Manco-Johnson M. Antiphospholipid antibodies and coagulation regulatory protein abnormalities in children with pulmonary emboli. J Pediatr Hematol Oncol. 1997 May-Jun. 19(3):202-7. [Medline].

  19. Dollery CM. Pulmonary embolism in parenteral nutrition. Arch Dis Child. 1996 Feb. 74(2):95-8. [Medline]. [Full Text].

  20. Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data. Arch Intern Med. 2003 Jul 28. 163(14):1711-7. [Medline].

  21. Burge AJ, Freeman KD, Klapper PJ, Haramati LB. Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era. Clin Radiol. 2008 Apr. 63(4):381-6. [Medline].

  22. DeMonaco NA, Dang Q, Kapoor WN, Ragni MV. Pulmonary embolism incidence is increasing with use of spiral computed tomography. Am J Med. 2008 Jul. 121(7):611-7. [Medline]. [Full Text].

  23. Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ 3rd. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998 Mar 23. 158(6):585-93. [Medline].

  24. Heit JA. The epidemiology of venous thromboembolism in the community. Arterioscler Thromb Vasc Biol. 2008 Mar. 28(3):370-2. [Medline]. [Full Text].

  25. Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis?. J R Soc Med. 1989 Apr. 82(4):203-5. [Medline]. [Full Text].

  26. Kotsakis A, Cook D, Griffith L, Anton N, Massicotte P, MacFarland K, et al. Clinically important venous thromboembolism in pediatric critical care: a Canadian survey. J Crit Care. 2005 Dec. 20(4):373-80. [Medline].

  27. Van Ommen CH, Peters M. Acute pulmonary embolism in childhood. Thromb Res. 2006. 118(1):13-25. [Medline].

  28. Kabrhel C, Varraso R, Goldhaber SZ, Rimm E, Camargo CA Jr. Physical inactivity and idiopathic pulmonary embolism in women: prospective study. BMJ. 2011 Jul 4. 343:d3867. [Medline].

  29. Schneider D, Lilienfeld DE, Im W. The epidemiology of pulmonary embolism: racial contrasts in incidence and in-hospital case fatality. J Natl Med Assoc. 2006 Dec. 98(12):1967-72. [Medline]. [Full Text].

  30. Meyer G, Planquette B, Sanchez O. Long-term outcome of pulmonary embolism. Curr Opin Hematol. 2008 Sep. 15(5):499-503. [Medline].

  31. Bernstein D, Coupey S, Schonberg SK. Pulmonary embolism in adolescents. Am J Dis Child. 1986 Jul. 140(7):667-71. [Medline].

  32. Evans DA, Wilmott RW. Pulmonary embolism in children. Pediatr Clin North Am. 1994 Jun. 41(3):569-84. [Medline].

  33. Rajpurkar M, Warrier I, Chitlur M, Sabo C, Frey MJ, Hollon W, et al. Pulmonary embolism-experience at a single children's hospital. Thromb Res. 2007. 119(6):699-703. [Medline].

  34. Kuklina EV, Meikle SF, Jamieson DJ, Whiteman MK, Barfield WD, Hillis SD, et al. Severe obstetric morbidity in the United States: 1998-2005. Obstet Gynecol. 2009 Feb. 113(2 Pt 1):293-9. [Medline]. [Full Text].

  35. Worsley DF, Alavi A. Comprehensive analysis of the results of the PIOPED Study. Prospective Investigation of Pulmonary Embolism Diagnosis Study. J Nucl Med. 1995 Dec. 36(12):2380-7. [Medline].

  36. Cavallazzi R, Nair A, Vasu T, Marik PE. Natriuretic peptides in acute pulmonary embolism: a systematic review. Intensive Care Med. 2008 Dec. 34(12):2147-56. [Medline].

  37. Alonso-Martínez JL, Urbieta-Echezarreta M, Anniccherico-Sánchez FJ, Abínzano-Guillén ML, Garcia-Sanchotena JL. N-terminal pro-B-type natriuretic peptide predicts the burden of pulmonary embolism. Am J Med Sci. 2009 Feb. 337(2):88-92. [Medline].

  38. Vanni S, Viviani G, Baioni M, Pepe G, Nazerian P, Socci F, et al. Prognostic value of plasma lactate levels among patients with acute pulmonary embolism: the thrombo-embolism lactate outcome study. Ann Emerg Med. 2013 Mar. 61(3):330-8. [Medline].

  39. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999 Apr 24. 353(9162):1386-9. [Medline].

  40. Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest. 2002 Mar. 121(3):877-905. [Medline].

  41. Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Massive pulmonary embolism. Circulation. 2006 Jan 31. 113(4):577-82. [Medline].

  42. [Guideline] Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014 Nov 14. 35 (43):3033-69, 3069a-3069k. [Medline].

  43. Vedovati MC, Becattini C, Agnelli G, Kamphuisen PW, Masotti L, Pruszczyk P, et al. MULTIDETECTOR COMPUTED TOMOGRAPHY FOR ACUTE PULMONARY EMBOLISM: EMBOLIC BURDEN AND CLINICAL OUTCOME. Chest. 2012 May 24. [Medline].

  44. Restrepo CS, Artunduaga M, Carrillo JA, Rivera AL, Ojeda P, Martinez-Jimenez S, et al. Silicone pulmonary embolism: report of 10 cases and review of the literature. J Comput Assist Tomogr. 2009 Mar-Apr. 33(2):233-7. [Medline].

  45. Vichinsky EP, Neumayr LD, Earles AN, Williams R, Lennette ET, Dean D, et al. Causes and outcomes of the acute chest syndrome in sickle cell disease. National Acute Chest Syndrome Study Group. N Engl J Med. 2000 Jun 22. 342(25):1855-65. [Medline].

  46. Douma RA, Mos IC, Erkens PM, Nizet TA, Durian MF, Hovens MM, et al. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. Ann Intern Med. 2011 Jun 7. 154(11):709-18. [Medline].

  47. Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med. 2004 Apr 20. 140(8):589-602. [Medline].

  48. Kearon C, Ginsberg JS, Douketis J, Turpie AG, Bates SM, Lee AY, et al. An evaluation of D-dimer in the diagnosis of pulmonary embolism: a randomized trial. Ann Intern Med. 2006 Jun 6. 144(11):812-21. [Medline].

  49. Geersing GJ, Erkens PM, Lucassen WA, Büller HR, Cate HT, Hoes AW, et al. Safe exclusion of pulmonary embolism using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study. BMJ. 2012 Oct 4. 345:e6564. [Medline]. [Full Text].

  50. Konstantinides S. Clinical practice. Acute pulmonary embolism. N Engl J Med. 2008 Dec 25. 359(26):2804-13. [Medline].

  51. Kline JA, Hogg MM, Courtney DM, Miller CD, Jones AE, Smithline HA, et al. D-dimer and exhaled CO2/O2 to detect segmental pulmonary embolism in moderate-risk patients. Am J Respir Crit Care Med. 2010 Sep 1. 182(5):669-75. [Medline]. [Full Text].

  52. Turedi S, Gunduz A, Mentese A, Topbas M, Karahan SC, Yeniocak S, et al. The value of ischemia-modified albumin compared with d-dimer in the diagnosis of pulmonary embolism. Respir Res. 2008 May 30. 9:49. [Medline]. [Full Text].

  53. Tick LW, Nijkeuter M, Kramer MH, Hovens MM, Büller HR, Leebeek FW, et al. High D-dimer levels increase the likelihood of pulmonary embolism. J Intern Med. 2008 Aug. 264(2):195-200. [Medline].

  54. Meyer T, Binder L, Hruska N, Luthe H, Buchwald AB. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction. J Am Coll Cardiol. 2000 Nov 1. 36(5):1632-6. [Medline].

  55. Jiménez D, Uresandi F, Otero R, Lobo JL, Monreal M, Martí D, et al. Troponin-based risk stratification of patients with acute nonmassive pulmonary embolism: systematic review and metaanalysis. Chest. 2009 Oct. 136(4):974-82. [Medline].

  56. Becattini C, Vedovati MC, Agnelli G. Diagnosis and prognosis of acute pulmonary embolism: focus on serum troponins. Expert Rev Mol Diagn. 2008 May. 8(3):339-49. [Medline].

  57. Kline JA, Zeitouni R, Marchick MR, Hernandez-Nino J, Rose GA. Comparison of 8 biomarkers for prediction of right ventricular hypokinesis 6 months after submassive pulmonary embolism. Am Heart J. 2008 Aug. 156(2):308-14. [Medline].

  58. Aksay E, Yanturali S, Kiyan S. Can elevated troponin I levels predict complicated clinical course and inhospital mortality in patients with acute pulmonary embolism?. Am J Emerg Med. 2007 Feb. 25(2):138-43. [Medline].

  59. Dellas C, Lankeit M, Reiner C, Schäfer K, Hasenfuß G, Konstantinides S. BMI-independent inverse relationship of plasma leptin levels with outcome in patients with acute pulmonary embolism. Int J Obes (Lond). 2012 Mar 20. [Medline].

  60. Söhne M, Ten Wolde M, Boomsma F, Reitsma JB, Douketis JD, Büller HR. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemost. 2006 Mar. 4(3):552-6. [Medline].

  61. Kucher N, Printzen G, Goldhaber SZ. Prognostic role of brain natriuretic peptide in acute pulmonary embolism. Circulation. 2003 May 27. 107(20):2545-7. [Medline].

  62. Klok FA, Mos IC, Huisman MV. Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis. Am J Respir Crit Care Med. 2008 Aug 15. 178(4):425-30. [Medline].

  63. Scherz N, Labarère J, Méan M, Ibrahim SA, Fine MJ, Aujesky D. Prognostic importance of hyponatremia in patients with acute pulmonary embolism. Am J Respir Crit Care Med. 2010 Nov 1. 182(9):1178-83. [Medline]. [Full Text].

  64. Ready T. Pulmonary Emboli Overdiagnosed by CT Angiography. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/807439. Accessed: July 15, 2013.

  65. Wiener RS, Schwartz LM, Woloshin S. When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found. BMJ. 2013 Jul 2. 347:f3368. [Medline].

  66. [Guideline] Remy-Jardin M, Pistolesi M, Goodman LR, Gefter WB, Gottschalk A, Mayo JR, et al. Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology. 2007 Nov. 245(2):315-29. [Medline].

  67. Patel S, Kazerooni EA. Helical CT for the evaluation of acute pulmonary embolism. AJR Am J Roentgenol. 2005 Jul. 185(1):135-49. [Medline].

  68. Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators. Radiology. 2007 Jan. 242(1):15-21. [Medline].

  69. [Guideline] Bettmann MA, Baginski SG, White RD, Woodard PK, Abbara S, Atalay MK, et al. ACR Appropriateness Criteria® acute chest pain--suspected pulmonary embolism. J Thorac Imaging. 2012 Mar. 27 (2):W28-31. [Medline].

  70. Ward MJ, Sodickson A, Diercks DB, Raja AS. Cost-effectiveness of lower extremity compression ultrasound in emergency department patients with a high risk of hemodynamically stable pulmonary embolism. Acad Emerg Med. 2011 Jan. 18(1):22-31. [Medline].

  71. Drescher FS, Chandrika S, Weir ID, et al. Effectiveness and acceptability of a computerized decision support system using modified Wells criteria for evaluation of suspected pulmonary embolism. Ann Emerg Med. 2011 Jun. 57(6):613-21. [Medline].

  72. Remy-Jardin M, Remy J, Deschildre F, Artaud D, Beregi JP, Hossein-Foucher C, et al. Diagnosis of pulmonary embolism with spiral CT: comparison with pulmonary angiography and scintigraphy. Radiology. 1996 Sep. 200(3):699-706. [Medline].

  73. Becattini C, Agnelli G, Vedovati MC, et al. Multidetector computed tomography for acute pulmonary embolism: diagnosis and risk stratification in a single test. Eur Heart J. 2011 Jul. 32(13):1657-63. [Medline].

  74. Henzler T, Roeger S, Meyer M, Schoepf UJ, Nance JW Jr, Haghi D, et al. Pulmonary embolism: CT signs and cardiac biomarkers for predicting right ventricular dysfunction. Eur Respir J. 2012 Apr. 39(4):919-26. [Medline].

  75. Gottschalk A, Stein PD, Sostman HD, Matta F, Beemath A. Very low probability interpretation of V/Q lung scans in combination with low probability objective clinical assessment reliably excludes pulmonary embolism: data from PIOPED II. J Nucl Med. 2007 Sep. 48(9):1411-5. [Medline].

  76. Gupta A, Frazer CK, Ferguson JM, Kumar AB, Davis SJ, Fallon MJ, et al. Acute pulmonary embolism: diagnosis with MR angiography. Radiology. 1999 Feb. 210(2):353-9. [Medline].

  77. Meaney JF, Weg JG, Chenevert TL, Stafford-Johnson D, Hamilton BH, Prince MR. Diagnosis of pulmonary embolism with magnetic resonance angiography. N Engl J Med. 1997 May 15. 336(20):1422-7. [Medline].

  78. Vanni S, Polidori G, Vergara R, Pepe G, Nazerian P, Moroni F, et al. Prognostic value of ECG among patients with acute pulmonary embolism and normal blood pressure. Am J Med. 2009 Mar. 122(3):257-64. [Medline].

  79. Boggs W. Bedside Echo Could Facilitate ER Diagnosis of Pulmonary Embolism. Medscape Medical News. Available at http://www.medscape.com/viewarticle/812942. Accessed: October 28, 2013.

  80. Dresden S, Mitchell P, Rahimi L, Leo M, Rubin-Smith J, Bibi S, et al. Right Ventricular Dilatation on Bedside Echocardiography Performed by Emergency Physicians Aids in the Diagnosis of Pulmonary Embolism. Ann Emerg Med. 2013 Sep 23. [Medline].

  81. Stein PD, Matta F. Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. Am J Med. 2012 May. 125(5):465-70. [Medline].

  82. Stein PD, Matta F, Keyes DC, Willyerd GL. Impact of Vena Cava Filters on In-hospital Case Fatality Rate from Pulmonary Embolism. Am J Med. 2012 May. 125(5):478-84. [Medline].

  83. Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014 Jun 18. 311(23):2414-21. [Medline].

  84. Meyer G, Vicaut E, Danays T, Agnelli G, Becattini C, Beyer-Westendorf J, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014 Apr 10. 370(15):1402-11. [Medline].

  85. Elliott CG. Fibrinolysis of pulmonary emboli--steer closer to Scylla. N Engl J Med. 2014 Apr 10. 370(15):1457-8. [Medline].

  86. Barclay L. Fibrinolysis for Pulmonary Embolism Effective but Risky. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/823427. Accessed: April 19, 2014.

  87. Aujesky D, Roy PM, Verschuren F, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet. 2011 Jul 2. 378(9785):41-8. [Medline].

  88. Büller HR, Prins MH, Lensin AW, Decousus H, Jacobson BF, Minar E, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012 Apr 5. 366(14):1287-97. [Medline].

  89. Bauersachs R, Berkowitz SD, Brenner B, Buller HR, Decousus H, Gallus AS, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010 Dec 23. 363(26):2499-510. [Medline]. [Full Text].

  90. Cohen AT, Dobromirski M. The use of rivaroxaban for short- and long-term treatment of venous thromboembolism. Thromb Haemost. 2012 Jun. 107(6):1035-43. [Medline].

  91. Romualdi E, Donadini MP, Ageno W. Oral rivaroxaban after symptomatic venous thromboembolism: the continued treatment study (EINSTEIN-extension study). Expert Rev Cardiovasc Ther. 2011 Jul. 9(7):841-4. [Medline].

  92. Hughes S. Rivaroxaban Stands up to standard anticoagulation for VTE treatment. Medscape Medical News. December 13, 2012. [Full Text].

  93. Buller HR, on behalf of the EINSTEIN Investigators. Oral rivaroxaban for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN DVT and EINSTEIN PE studies [abstract 20]. Presented at: 54th Annual Meeting and Exposition of the American Society of Hematology; December 8, 2012; Atlanta, Ga. [Full Text].

  94. Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M, et al. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med. 2013 Aug 29. 369(9):799-808. [Medline]. [Full Text].

  95. Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M, et al. Apixaban for extended treatment of venous thromboembolism. N Engl J Med. 2013 Feb 21. 368(8):699-708. [Medline]. [Full Text].

  96. Schulman S, Kearon C, Kakkar AK, Mismetti P, Schellong S, Eriksson H, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009 Dec 10. 361(24):2342-52. [Medline]. [Full Text].

  97. Schulman S, Kakkar AK, Goldhaber SZ, Schellong S, Eriksson H, Mismetti P, et al. Treatment of acute venous thromboembolism with dabigatran or warfarin and pooled analysis. Circulation. 2014 Feb 18. 129(7):764-72. [Medline].

  98. Büller HR, Décousus H, Grosso MA, Mercuri M, Middeldorp S, Prins MH, et al. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med. 2013 Oct 10. 369(15):1406-15. [Medline]. [Full Text].

  99. Garcia D, Ageno W, Libby E. Update on the diagnosis and management of pulmonary embolism. Br J Haematol. 2005 Nov. 131(3):301-12. [Medline].

  100. Campbell IA, Bentley DP, Prescott RJ, Routledge PA, Shetty HG, Williamson IJ. Anticoagulation for three versus six months in patients with deep vein thrombosis or pulmonary embolism, or both: randomised trial. BMJ. 2007 Mar 31. 334(7595):674. [Medline]. [Full Text].

  101. Pinede L, Ninet J, Duhaut P, Chabaud S, Demolombe-Rague S, Durieu I, et al. Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circulation. 2001 May 22. 103(20):2453-60. [Medline].

  102. Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, et al. Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension: A Scientific Statement From the American Heart Association. Circulation. 2011 Apr 26. 123(16):1788-1830. [Medline]. [Full Text].

  103. Ballew KA, Philbrick JT, Becker DM. Vena cava filter devices. Clin Chest Med. 1995 Jun. 16(2):295-305. [Medline].

  104. Dempfle CE, Elmas E, Link A, et al. Endogenous plasma activated protein C levels and the effect of enoxaparin and drotrecogin alfa (activated) on markers of coagulation activation and fibrinolysis in pulmonary embolism. Crit Care. 2011 Jan 17. 15(1):R23. [Medline].

  105. Hippisley-Cox J, Coupland C. Development and validation of risk prediction algorithm (QThrombosis) to estimate future risk of venous thromboembolism: prospective cohort study. BMJ. 2011 Aug 16. 343:d4656. [Medline]. [Full Text].

  106. Boutitie F, Pinede L, Schulman S, Agnelli G, Raskob G, Julian J, et al. Influence of preceding length of anticoagulant treatment and initial presentation of venous thromboembolism on risk of recurrence after stopping treatment: analysis of individual participants' data from seven trials. BMJ. 2011 May 24. 342:d3036. [Medline]. [Full Text].

  107. [Guideline] Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD, et al. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015 Nov 3. 163 (9):701-11. [Medline].

  108. [Guideline] Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, et al. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011 Jun. 57 (6):628-652.e75. [Medline].

  109. [Guideline] Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb. 149 (2):315-52. [Medline].

  110. [Guideline] James A, Committee on Practice Bulletins—Obstetrics. Practice bulletin no. 123: thromboembolism in pregnancy. Obstet Gynecol. 2011 Sep. 118 (3):718-29. [Medline].

  111. Wood S. FDA Approves Apixaban (Eliquis) for DVT/PE Treatment, Recurrences. Medscape. Aug 21 2014. [Full Text].

  112. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun. 133(6 Suppl):381S-453S. [Medline].

 
Previous
Next
 
A large pulmonary artery thrombus in a hospitalized patient who died suddenly.
Pulmonary embolism was identified as the cause of death in a patient who developed shortness of breath while hospitalized for hip joint surgery. This is a close-up view.
Lung infarction secondary to pulmonary embolism occurs rarely.
Posteroanterior and lateral chest radiograph findings are normal, which is the usual finding in patients with pulmonary embolism.
High-probability perfusion lung scan shows segmental perfusion defects in the right upper lobe and subsegmental perfusion defects in right lower lobe, left upper lobe, and left lower lobe.
A normal ventilation scan will make the noted defects in the previous image a mismatch and, hence, a high-probability ventilation-perfusion scan.
Anterior views of perfusion and ventilation scans are shown here. A perfusion defect is present in the left lower lobe, but perfusion to this lobe is intact, making this a high-probability scan.
A segmental ventilation perfusion mismatch is evident in a left anterior oblique projection.
A pulmonary angiogram shows the abrupt termination of the ascending branch of the right upper-lobe artery, confirming the diagnosis of pulmonary embolism.
A chest radiograph with normal findings in a 64-year-old woman who presented with worsening breathlessness.
This perfusion scan shows bilateral perfusion defects. The ventilation scan findings were normal; therefore, these are mismatches, and this is a high-probability scan.
This ultrasonogram shows a thrombus in the distal superficial saphenous vein, which is under the artery.
A posteroanterior chest radiograph showing a peripheral wedge-shaped infiltrate caused by pulmonary infarction secondary to pulmonary embolism. Hampton hump is a rare and nonspecific finding. Courtesy of Justin Wong, MD.
Computed tomography angiogram in a 53-year-old man with acute pulmonary embolism. This image shows an intraluminal filling defect that occludes the anterior basal segmental artery of the right lower lobe. Also present is an infarction of the corresponding lung, which is indicated by a triangular, pleura-based consolidation (Hampton hump).
Computed tomography angiography in a young man who experienced acute chest pain and shortness of breath after a transcontinental flight. This image demonstrates a clot in the anterior segmental artery in the left upper lung (LA2) and a clot in the anterior segmental artery in the right upper lung (RA2).
Computed tomography angiogram in a 55-year-old man with possible pulmonary embolism. This image was obtained at the level of the lower lobes and shows perivascular segmental enlarged lymph nodes as well as prominent extraluminal soft tissue interposed between the artery and the bronchus.
Computed tomography venograms in a 65-year-old man with possible pulmonary embolism. This image shows acute deep venous thrombosis with intraluminal filling defects in the bilateral superficial femoral veins.
The pathophysiology of pulmonary embolism. Although pulmonary embolism can arise from anywhere in the body, most commonly it arises from the calf veins. The venous thrombi predominately originate in venous valve pockets (inset) and at other sites of presumed venous stasis. To reach the lungs, thromboemboli travel through the right side of the heart. RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle.
A spiral CT scan shows thrombus in bilateral main pulmonary arteries.
CT scan of the same chest depicted in Image 18. Courtesy of Justin Wong, MD.
Longitudinal ultrasound image of partially recanalized thrombus in the femoral vein at mid thigh.
Sequential images demonstrate treatment of iliofemoral deep venous thrombosis due to May-Thurner (Cockett) syndrome. Far left, view of the entire pelvis demonstrates iliac occlusion. Middle left, after 12 hours of catheter-directed thrombolysis, an obstruction at the left common iliac vein is evident. Middle right, after 24 hours of thrombolysis, a bandlike obstruction is seen; this is the impression made by the overlying right common iliac artery. Far left, after stent placement, image shows wide patency and rapid flow through the previously obstructed region. Note that the patient is in the prone position in all views. (Right and left are reversed.)
Lower-extremity venogram shows outlining of an acute deep venous thrombosis in the popliteal vein with contrast enhancement.
Lower-extremity venogram shows a nonocclusive chronic thrombus. The superficial femoral vein (lateral vein) has the appearance of 2 parallel veins, when in fact, it is 1 lumen containing a chronic linear thrombus. Although the chronic clot is not obstructive after it recanalizes, it effectively causes the venous valves to adhere in an open position, predisposing the patient to reflux in the involved segment.
Pulmonary embolus.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.