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Pulmonary Venous Thromboembolism

For further information, see CMDT Part 9-25: Pulmonary Venous Thromboembolism

Key Features

Essentials of Diagnosis

  • May present with one or more of the following:

    • Dyspnea

    • Pleuritic chest pain

    • Hemoptysis

    • Syncope

  • Tachypnea, tachycardia, hypoxia (alone or in combination) may be present

  • Risk stratification with clinical scores, cardiac biomarkers, and right ventricular imaging is key for management

General Considerations

  • Venous thromboembolism (VTE), often referred to as pulmonary embolism (PE), is often clinically silent until it presents with significant morbidity or mortality

  • Pulmonary thromboemboli most often originate in deep veins of the lower extremities

  • Risk factors for PE include the Virchow triad, which comprises

    • Venous stasis (eg, due to immobility, hyperviscosity, increased central venous pressures)

    • Injury to the vessel wall (eg, due to prior episodes of thrombosis, orthopedic surgery, trauma)

    • Hypercoagulability (eg, due to medications, disease, inherited gene defects or acquired thrombophilias)

  • Pulmonary thromboembolism (PE) develops in 50–60% of patients with proximal lower extremity deep venous thrombosis (DVT); 50% of these events are asymptomatic

  • Hypoxemia results from vascular obstruction leading to dead space ventilation, right-to-left shunting, and decreased cardiac output

  • Other types of pulmonary emboli

    • Fat embolism

    • Air embolism

    • Amniotic fluid embolism

    • Septic embolism (eg, endocarditis)

    • Tumor embolism (eg, renal cell carcinoma)

    • Foreign body embolism (eg, talc in injection drug use)

    • Parasite egg embolism (schistosomiasis)

Demographics

  • Third most common cause of death in hospitalized patients

  • Most cases are not recognized antemortem

Clinical Findings

Symptoms and Signs

  • See Table 9–18

  • Clinical symptoms and signs are similar to those of other cardiopulmonary conditions

  • Dyspnea and chest pain on inspiration are common

Table 9–18.Clinical prediction rule for PE.
View Table||Download (.pdf)
Table 9–18. Clinical prediction rule for PE.
Variable Points
Clinical symptoms and signs of DVT (leg swelling and pain with palpation of deep veins) 3.0
Alternative diagnosis less likely than PE 3.0
Heart rate > 100 beats/minute 1.5
Immobilization for > 3 days or surgery in previous 4 weeks 1.5
Previous PE or DVT 1.5
Hemoptysis 1.0
Cancer (with treatment within past 6 months or palliative care) 1.0
Add Points to determine Score, then refer to probability assessments below:  
Three-tiered clinical probability assessment (Wells criteria) Score
High > 6.0
Moderate 2.0 to 6.0
Low < 2.0
Dichotomous clinical probability assessment (Modified Wells criteria) Score
PE likely > 4.0
PE unlikely < or = 4.0

Data from Wells PS et al. Derivation of a simple clinical model to categorize patients’ probability of pulmonary embolism: increasing the models’ utility with the SimpliRED D-dimer. Thromb Haemost. 2000;83:416.

Differential Diagnosis

  • Myocardial infarction

  • Pneumonia

  • Pericarditis

  • Heart failure

  • Pleuritis (pleurisy)

  • Pneumothorax

  • Pericardial tamponade

Diagnosis

  • Diagnosis primarily relies on clinical prediction scores ...

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