Acute pulmonary embolism: risk stratification in the emergency department

Abstract

Pulmonary embolism is a common disease associated with a high mortality rate. Death due to pulmonary embolism occurs more commonly in undiagnosed patients before hospital admission or during the initial in-hospital stay. Thus, mortality could be reduced by prompt diagnosis, early prognostic stratification and more intensive treatment in patients with adverse prognosis. Mortality is particularly high in patients with pulmonary embolism presenting with arterial hypotension or cardiogenic shock. In patients with pulmonary embolism and normal blood pressure, a number of clinical features and objective findings have been associated with a high risk of adverse in-hospital outcome. Advanced age and concomitant cardiopulmonary disease are clinical risk factors for in-hospital mortality. The Bburden of thromboembolism, as assessed by lung scan or spiral CT, and right ventricle overload, as assessed by echocardiography and probably spiral CT, have been claimed to be risk factors for in-hospital mortality. Elevated serum levels of troponins have been shown to be associated with right ventricular overload and adverse in-hospital outcomes in patients with pulmonary embolism. Despite the currently available evidence, no definite prognostic value can be assigned to any of the individual risk factors or cluster of them. Large prospective trials should be carried out to validate individual risk factors or clusters of risk factors able to identify patients with acute pulmonary embolism at high risk for in-hospital mortality. These patients could afford the trade-off of an increased risk of side effects related to a more aggressive treatment, such as thrombolysis or surgical or interventional procedures.

The role of ST-segment elevation in lead aVR in the risk assessment of patients with acute pulmonary embolism

“…Risk stratification of patients with APE is based on haemodynamic parameters like the presence of hypotension, shock or cardiac arrest and on markers of right ventricular ischemia-like cardiac troponins and/or signs of right ventricular dysfunction on echocardiography or CT angiography [2,[30][31][32][33][34].…”

Outpatient treatment and early discharge of symptomatic pulmonary embolism: a systematic review

“…However, no quality scoring systems or quality scales are widely accepted, and, even if the choice of quality criteria can be criticised, assessing new criteria would not improve study quality [6]. Thirdly, stratification of patients based on new prognostic markers, such as troponin, brain natriuretic peptide and echocardiographic parameters, is not available, and it is not yet possible to identify subgroups of patients who may be safely treated at home [47]. Only in one study were patients considered eligible for the outpatient treatment based on a well-defined prognostic score, the Geneva score [19,39].…”

“…Only in one study were patients considered eligible for the outpatient treatment based on a well-defined prognostic score, the Geneva score [19,39]. However, no consensus exists regarding which single marker or score is the most reliable and thus the best indicator of prognosis [47]. Future studies could explore the role of prognostic markers in improving the selection process of PE patients eligible for outpatient management [48].…”

Mean Platelet Volume: A Simple Tool For Early Risk Stratification Of Pulmonary Embolism

“…In patients with the suspicion of PE, first of all risk stratification should be performed. Especially among hemodynamically stable patients, in determination of high risk group, echocardiographic findings and cardiac markers are commonly used (2,3,4). However, it is not always easy to attain these procedures.…”