Diagnosis and management of pulmonary embolism in the elderly

Abstract

a b s t r a c t a r t i c l e i n f oElderly patients are a population not only at particularly high risk of venous thromboembolism including pulmonary embolism (PE), but also at high risk of adverse clinical outcomes and treatment-related complications. Major progresses have been achieved in the diagnosis and treatment of PE over the last two decades. Nevertheless, some of elderly patients' specificities still represent important challenges in the management of PE in this population, from its suspicion to its diagnosis and treatment, and are discussed in this review. Perspectives for the future are from a diagnostic point of view the potential implementation of age-adjusted D-dimer cut-offs that will allow ruling out PE in a greater proportion of elderly patients without the need for thoracic imaging. From a therapeutic point of view, acquisition of post-marketing clinical experience with the use of new oral anticoagulants is still necessary, and in the meantime, these drugs should be prescribed with great caution in thoroughly selected elderly patients.

Global Emergency Medicine Journal Club: A Social Media Discussion About the Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism Trial

“…Furthermore, the risk of pulmonary embolisms increases with age, 6 and older patients often present with more severe clinical features. 7 Kirschner concluded the following: "[The differences in mean age are] probably going to affect the calculated sensitivities from the study. The reasoning lies really in what we call spectrum effect-often called spectrum bias.…”

Pulmonary embolism in old age: usefulness of risk stratification in clinical decision-making

“…1 Elderly patients are not only at particularly high risk for PE, but also at high risk of adverse clinical outcomes and treatment-related complications. 2 PE has a wide range of clinical presentations, that are associated with different clinical severity and risk for adverse short-term outcomes. 3 Patients with persistent arterial hypotension (<90 mm Hg) or cardiogenic shock represent only about 5% of all patients, but have a high risk of early death.…”

Diagnostic utility of an age‐specific cut‐off for d‐dimer for pulmonary embolism assessment when used with various pulmonary embolism risk scores

“…However, the non‐specific and variable clinical presentation of PE creates diagnostic difficulty for clinicians, especially in older patients . Typical signs and symptoms such as dyspnoea and pleuritic chest pain are not as frequently reported in older populations, widening the spectrum of presentations for which PE must be considered . The current recommended diagnostic workup of PE includes the sequential use of risk assessment and diagnostic tests.…”

“…In fact, d‐dimer testing is able to rule out PE in 60% of patients aged <40 years but only 5% for patients aged >80 years . This results in an increased number of potentially unnecessary and expensive advanced imaging tests in older patients who are also at increased risk of adverse clinical outcomes, such as contrast‐induced nephropathy …”