Massive pulmonary embolism leading to cardiac arrest is associated with consumptive coagulopathy presenting as disseminated intravascular coagulation

Abstract

To cite this article: Leitner JM, Jilma B, Spiel AO, Sterz F, Laggner AN, Janata KM. Massive pulmonary embolism leading to cardiac arrest is associated with consumptive coagulopathy presenting as disseminated intravascular coagulation. J Thromb Haemost 2010; 8: 1477-82.See also Levi M. Disseminated intravascular coagulation or extended intravascular coagulation in massive pulmonary embolism. This issue, pp 1475-6; Thachil J. DIC score predicts mortality in massive clot coagulopathy as a result of extensive pulmonary embolism: a rebuttal. This issue, pp 1657-8; Leitner JM, Janata-Schwatzek K, Spiel AO, Sterz F, Laggner AN, Jilma B. DIC score predicts mortality in massive clot coagulopathy as a result of extensive pulmonary embolism: reply to a rebuttal. This issue, pp 1658-9.Summary. Background: A consumptive coagulopathy resembling disseminated intravascular coagulation (DIC) has been seen in patients with massive pulmonary embolism (PE). We hypothesized that a DIC-like condition is relevant in patients whose pulmonary embolism leads to cardiopulmonary arrest and cardiopulmonary resuscitation (CPR). Methods: This hypothesis was tested by the use of a database consisting of all cases of PE diagnosed at the Department of Emergency Medicine from June 1993 to October 2007. Out of 1018 cases with PE, 113 patients underwent CPR. In this cohort study, the resuscitated patients were compared with those with PE but without CPR. Results: Patients with PE and CPR had 3-fold higher D-dimer, prolonged prothrombin time (PT), reduced platelet counts and lower fibrinogen and antithrombin (AT) levels compared with PE patients without cardiac arrest (P < 0.001 for all). Among patients with PE and CPR, Ddimer was abnormal in 100%, PT in 44%, AT in 53%, fibrinogen in 19% and platelets in 25%. In comparison, PE without CPR was associated with abnormal D-dimer in 99%, abnormal PT in 15%, low AT in 6%, low fibrinogen in 1% and low platelets in 2%. Nine per cent of the resuscitated patients had a DIC score ‡ 5, indicating overt DIC. The DIC score highly correlated with 1-year and in-hospital mortality. Conclusions: Massive PE leading to CPR is associated with consumptive coagulopathy and overt DIC. In resuscitated patients, DIC markers may indicate pulmonary embolism as the underlying cause of arrest.

Severe pulmonary embolism decreases plasma L-arginine

“…Preliminary evidence from animal models and humans suggests that acute PE is associated with intravascular haemolysis, related to the severity of PE [3][4][5][6][7][8]. Intravascular haemolysis liberates haemoglobin and diffusible haem, both of which directly bind NO.…”

Recombinant thrombomodulin protects mice against histoneinduced lethal thromboembolism

“…The consumptive coagulopathy seen in our murine model differs from traditional DIC in terms of time course (minutes vs. days) and extent of disorder (massive thrombosis in lung vs. systemic thrombosis) although these two conditions are difficult to distinguish by clinical laboratory findings. A similar example is that patients with massive pulmonary embolism develop a state of consumptive coagulopathy resembling DIC [37]. In these Figure 5.…”

DIC score predicts mortality in massive clot coagulopathy as a result of extensive pulmonary embolism: reply to a rebuttal

“…Probably, the most important finding of our study [2] is that the DIC score predicted mortality, when we applied the DIC score to massive clot coagulopathy induced by pulmonary embolism. This effect was particularly pronounced in patients without cardiopulmonary resuscitation.…”