Korean Circ J.  2018 May;48(5):365-381. 10.4070/kcj.2017.0314.

Acute Pulmonary Embolism: Focus on the Clinical Picture

• Morrone D
• Morrone V

• KMID: 2414906
• DOI: http://doi.org/10.4070/kcj.2017.0314

Abstract

Acute pulmonary embolism (APE) is characterized by numerous clinical manifestations which are the result of a complex interplay between different organs; the symptoms are therefore various and part of a complex clinical picture. For this reason, it may not be easy to make an immediate diagnosis. This is a comprehensive review of the literature on all the various clinical pictures in order to help physicians to promptly recognize this clinical condition, remembering that our leading role as cardiologists depends on and is influenced by our knowledge and working methods.

Keyword

Pulmonary embolism; Sudden cardiac death; Syncope; Deep vein thrombosis

MeSH Terms

Death, Sudden, Cardiac
Diagnosis
Pulmonary Embolism*
Syncope
Venous Thrombosis

Figure

• 

  Figure 1 Apparatus involvment in PE. PE may present under several clinical pictures. Careful patient evaluation is the key role in order to do not miss the diagnosis. AF = atrial fibrillation; BBDX = Blocco di Branca Destra; DVT = deep venous thrombosis; PA = pulmonary artery; PE = pulmonary embolism; RV = right ventricular.

Reference

1. Marshall PS, Mathews KS, Siegel MD. Diagnosis and management of life-threatening pulmonary embolism. J Intensive Care Med. 2011; 26:275–294.

2. Heit JA. The epidemiology of venous thromboembolism in the community. Arterioscler Thromb Vasc Biol. 2008; 28:370–372.

3. Cohen AT, Agnelli G, Anderson FA, et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007; 98:756–764.

4. Eurostat: Eurostat statistics on health and safety 2001 [Internet]. Luxembourg: Eurostat;2001. Available from: http://ec.europa.eu/eurostat/search?p_auth=2D3nmKEv&p_p_id=estatsearchportlet_WAR_estatsearchportlet&p_p_lifecycle=1&p_p_state=maximized&p_p_mode=view&_estatsearchportlet_WAR_estatsearchportlet_action=search&text=PULMONARY+EMBOLISM.

5. Klok FA, van Kralingen KW, van Dijk AP, et al. Quality of life in long-term survivors of acute pulmonary embolism. Chest. 2010; 138:1432–1440.

6. Fanikos J, Piazza G, Zayaruzny M, Goldhaber SZ. Long-term complications of medical patients with hospital-acquired venous thromboembolism. Thromb Haemost. 2009; 102:688–693.

7. Stein PD, Henry JW. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy. Chest. 1995; 108:978–981.

8. Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ. Predictors of survival after deep vein thrombosis and pulmonary embolism: a population-based, cohort study. Arch Intern Med. 1999; 159:445–453.

9. Pichereau C, Maury E, Monnier-Cholley L, et al. Post-mortem CT scan with contrast injection and chest compression to diagnose pulmonary embolism. Intensive Care Med. 2015; 41:167–168.

10. Opinions regarding the diagnosis and management of venous thromboembolic disease. ACCP Consensus Committee on Pulmonary Embolism. American College of Chest Physicians. Chest. 1998; 113:499–504.

11. Laporte S, Mismetti P, Décousus H, et al. Clinical predictors for fatal pulmonary embolism in 15,520 patients with venous thromboembolism: findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) Registry. Circulation. 2008; 117:1711–1716.

12. Tzoran I, Brenner B, Papadakis M, Di Micco P, Monreal M. VTE registry: what can be learned from RIETE? Rambam Maimonides Med J. 2014; 5:e0037.

13. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999; 353:1386–1389.

14. Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med. 2000; 160:809–815.

15. Pineda LA, Hathwar VS, Grant BJ. Clinical suspicion of fatal pulmonary embolism. Chest. 2001; 120:791–795.

16. Babak S, Sriram KB. Misinterpreting risk and test results delays diagnosis in a patient with pulmonary embolism. BMJ Case Rep. 2014; 2014:bcr2014204172.

17. Cohen AT, Edmondson RA, Phillips MJ, et al. The changing pattern of venous thromboembolic disease. Haemostasis. 1996; 26:65–71.

18. Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? J R Soc Med. 1989; 82:203–205.

19. Pollack CV, Schreiber D, Goldhaber SZ, et al. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry). J Am Coll Cardiol. 2011; 57:700–706.

20. Stein PD, Henry JW. Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes. Chest. 1997; 112:974–979.

21. Thames MD, Alpert JS, Dalen JE. Syncope in patients with pulmonary embolism. JAMA. 1977; 238:2509–2511.

22. Islam M, Filopei J, Frank M, et al. Pulmonary infarction secondary to pulmonary embolism: an evolving paradigm. Respirology. 2018; Epub ahead of print.

23. Jaff MR, McMurtry MS, Archer SL, 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; 123:1788–1830.

24. Adabag AS, Luepker RV, Roger VL, Gersh BJ. Sudden cardiac death: epidemiology and risk factors. Nat Rev Cardiol. 2010; 7:216–225.

25. Zipes DP, Wellens HJ. Sudden cardiac death. Circulation. 1998; 98:2334–2351.

26. Knight B. Forensic pathology. 2nd ed. London: Edward Arnold;1996.

27. Chugh SS. Sudden cardiac death with apparently normal heart: clinical implications of progress in pathophysiology. Card Electrophysiol Rev. 2001; 5:394–402.

28. Eckart RE, Shry EA, Burke AP, et al. Sudden death in young adults: an autopsy-based series of a population undergoing active surveillance. J Am Coll Cardiol. 2011; 58:1254–1261.

29. Lucena J, Rico A, Vázquez R, et al. Pulmonary embolism and sudden-unexpected death: prospective study on 2477 forensic autopsies performed at the Institute of Legal Medicine in Seville. J Forensic Leg Med. 2009; 16:196–201.

30. Kürkciyan I, Meron G, Behringer W, et al. Accuracy and impact of presumed cause in patients with cardiac arrest. Circulation. 1998; 98:766–771.

31. Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010; 38:S495–S501.

32. Heit JA. The epidemiology of venous thromboembolism in the community: implications for prevention and management. J Thromb Thrombolysis. 2006; 21:23–29.

33. Patriquin L, Khorasani R, Polak JF. Correlation of diagnostic imaging and subsequent autopsy findings in patients with pulmonary embolism. AJR Am J Roentgenol. 1998; 171:347–349.

34. Bharadwaj RS, Slade TB. Diagnosis of pulmonary thromboembolism in psychiatric patients. Prim Care Companion CNS Disord. 2011; 13:PCC.10l01076.

35. Bougouin W, Marijon E, Planquette B, et al. Factors associated with pulmonary embolism-related sudden cardiac arrest. Circulation. 2016; 134:2125–2127.

36. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation. 2012; 125:e2–220.

37. Rodger MA, Carrier M, Jones GN, et al. Diagnostic value of arterial blood gas measurement in suspected pulmonary embolism. Am J Respir Crit Care Med. 2000; 162:2105–2108.

38. Stein PD, Goldhaber SZ, Henry JW, Miller AC. Arterial blood gas analysis in the assessment of suspected acute pulmonary embolism. Chest. 1996; 109:78–81.

39. Geibel A, Zehender M, Kasper W, et al. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. Eur Respir J. 2005; 25:843–848.

40. Page IH. Serotonin (5-hydroxytryptamine); the last four years. Physiol Rev. 1958; 38:277–335.

41. Lewis GP. Active polypeptides derived from plasma proteins. Physiol Rev. 1960; 40:647–676.

42. Boyer NH, Curry JJ. Bronchospasm associated with pulmonary embolism. Arch Intern Med (Chic). 1944; 73:403–409.

43. Xu K, Tang X, Song Y, Chen Z. The diagnostic dilemma between pulmonary embolism with positive chest imaging and pneumonia: a case report and literature review. J Transl Med Epidemiol. 2015; 3:1039.

44. Karabulut N, Kiroğlu Y. Relationship of parenchymal and pleural abnormalities with acute pulmonary embolism: CT findings in patients with and without embolism. Diagn Interv Radiol. 2008; 14:189–196.

45. Duru S, Keleşoğlu A, Ardıç S. Clinical update on pulmonary embolism. Arch Med Sci. 2014; 10:557–565.

46. Konstantinides S. Pulmonary embolism: impact of right ventricular dysfunction. Curr Opin Cardiol. 2005; 20:496–501.

47. Fonarow GC, Abraham WT, Albert NM, et al. Factors identified as precipitating hospital admissions for heart failure and clinical outcomes: findings from OPTIMIZE-HF. Arch Intern Med. 2008; 168:847–854.

48. McMichael J. Pulmonary heart disease acute and chronic. Br Heart J. 1948; 10:80–87.

49. McIntyre KM, Sasahara AA. The hemodynamic response to pulmonary embolism in patients without prior cardiopulmonary disease. Am J Cardiol. 1971; 28:288–294.

50. Wolfe MW, Lee RT, Feldstein ML. Prognostic significance of right ventricular hypokinesis and perfusion lung scan defects in pulmonary embolism. Am Heart J. 1994; 127:1371–1375.

51. McConnell MV, Solomon SD, Rayan ME, et al. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996; 78:469–473.

52. Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest. 2002; 121:877–905.

53. Luisada AA, Cardi L. Acute pulmonary edema; pathology, physiology and clinical management. Circulation. 1956; 13:113–135.

54. Harjola VP, Mebazaa A, Čelutkienė J, et al. Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the European Society of Cardiology. Eur J Heart Fail. 2016; 18:226–241.

55. Wolff L. Pulmonary embolism. Circulation. 1952; 6:768–776.

56. ESC Committee for Practice guidelines (CPG). Konstantinides SV, Torbicki A, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2014; 35:3033–3073.

57. Amini R, Jyothidasan A, Poommipanit P, Kapoor D. EKG findings mimicking left main coronary disease in a patient with acute massive pulmonary embolism. J Am Coll Cardiol. 2014; 63:suppl. A699.

58. Manne JR. Acute ST segment elevation in a patient with massive pulmonary embolism mimicking acute left main coronary artery obstruction. J Am Coll Cardiol. 2016; 67:1118.

59. Ciliberti P, Rapezzi C, Villani C, Boriani G. Massive pulmonary embolism with acute coronary syndrome-like electrocardiogram mimicking acute left main coronary artery obstruction. J Emerg Med. 2012; 43:e255–e258.

60. Kosuge M, Ebina T, Hibi K, et al. Simple electrocardiographic criteria for discriminating between acute pulmonary embolism and acute coronary syndrome. J Am Coll Cardiol. 2016; 67:528.

61. Kosuge M, Ebina T, Hibi K, et al. Differences in negative T waves among acute coronary syndrome, acute pulmonary embolism, and Takotsubo cardiomyopathy. Eur Heart J Acute Cardiovasc Care. 2012; 1:349–357.

62. Yaméogo NV, Mbaye A, Kagambèga LJ, et al. Pulmonary embolism mimicking acute anterior myocardial infarction: diagnostic trap. Ann Cardiol Angeiol (Paris). 2011; 60:169–172.

63. Falterman TJ, Martinez JA, Daberkow D, Weiss LD. Pulmonary embolism with ST segment elevation in leads V1 to V4: case report and review of the literature regarding electrocardiographic changes in acute pulmonary embolism. J Emerg Med. 2001; 21:255–261.

64. Omar HR. ST-segment elevation in V1-V4 in acute pulmonary embolism: a case presentation and review of literature. Eur Heart J Acute Cardiovasc Care. 2016; 5:579–586.

65. Mittal SR, Maheshwari M. Electrocardiographic changes in submassive pulmonary embolism. Indian Heart J. 2005; 57:80–81.

66. Duplyakov D, Kurakina E, Pavlova T, et al. Value of syncope in patients with high-to-intermediate risk pulmonary artery embolism. Eur Heart J Acute Cardiovasc Care. 2015; 4:353–358.

67. Jenab Y, Lotfi-Tokaldany M, Alemzadeh-Ansari MJ, et al. Correlates of syncope in patients with acute pulmonary thromboembolism. Clin Appl Thromb Hemost. 2015; 21:772–776.

68. Yamaki T, Nozaki M, Sakurai H, et al. Presence of lower limb deep venous thrombosis and prognosis in patients with symptomatic pulmonary embolism: preliminary report. Eur J Vasc Endovasc Surg. 2009; 37:225–231.

69. Jiménez D, Aujesky D, Díaz G, et al. Prognostic significance of deep vein thrombosis in patients presenting with acute symptomatic pulmonary embolism. Am J Respir Crit Care Med. 2010; 181:983–991.

70. Lin JF, Li YC, Yang PL. A case of massive pulmonary embolism with ST elevation in leads V1-4. Circ J. 2009; 73:1157–1159.

71. Mittal SR, Arora H. Pulmonary embolism with isolated right ventricular infarction. Indian Heart J. 2001; 53:218–220.

72. Mittal SR, Jain S, Maheshwari S. Pulmonary embolism with isolated right ventricular infarction. Indian Heart J. 1996; 48:704–706.

73. Jerjes Sánchez C, Gutiérrez-Fajardo P, Ramírez-Rivera A, et al. Acute infarct of the right ventricle secondary to a massive pulmonary thromboembolism. Arch Inst Cardiol Mex. 1995; 65:65–73.

74. Olivares-Reyes A, Chan S, Lazar EJ, Bandlamudi K, Narla V, Ong K. Atrial septal aneurysm: a new classification in two hundred five adults. J Am Soc Echocardiogr. 1997; 10:644–656.

75. Kleber FX, Hauschild T, Schulz A. Paradoxical embolic myocardial infarction. J Am Coll Cardiol. 2014; 64:TCT-163.

76. Wąsek WC, Samul W, Ryczek R, Skrobowski A. Unique case of ST-segment-elevation myocardial infarction related to paradoxical embolization and simultaneous pulmonary embolization: clinical considerations on indications for patent foramen ovale closure in no-guidelines land. Circulation. 2015; 131:1214–1223.

77. Yildiz A, Bostan C, Akin F, Arat Ozkan A, Gurmen T. Concurrent pulmonary embolism and acute coronary syndrome with dynamic electrocardiographic changes. Am J Emerg Med. 2012; 30:637.e1–637.e4.

78. Windecker S, Stortecky S, Meier B. Paradoxical embolism. J Am Coll Cardiol. 2014; 64:403–415.

79. Carey HB, Boltax R, Dickey KW, Finkelstein FO. Bilateral renal infarction secondary to paradoxical embolism. Am J Kidney Dis. 1999; 34:752–755.

80. Vicente DC, Kazmers A. Acute mesenteric ischemia. Curr Opin Cardiol. 1999; 14:453–458.

81. Loscalzo J. Paradoxical embolism: clinical presentation, diagnostic strategies, and therapeutic options. Am Heart J. 1986; 112:141–145.

82. Wei F, Zhang Y, Tian H, Zhang J, Ma Q. Pulmonary hypertension and massive or sub-massive pulmonary embolism are the high risk factors for paradoxical peripheral arterial embolism. J Am Coll Cardiol. 2016; 68:C154.

83. Akrawinthawong K, Damrongwatanasuk R, Abuzahra M. Acute limb ischemia and silent pulmonary emboli as a key to identify thrombus-in-transit through patent foramen ovale. J Am Coll Cardiol. 2016; 67:1194.

84. Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H. Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation. 1998; 97:1946–1951.

85. Di Tullio M, Sacco RL, Venketasubramanian N, Sherman D, Mohr JP, Homma S. Comparison of diagnostic techniques for the detection of a patent foramen ovale in stroke patients. Stroke. 1993; 24:1020–1024.

86. Pinto FJ. When and how to diagnose patent foramen ovale. Heart. 2005; 91:438–440.

87. Prandoni P, Lensing AW, Prins MH, et al. Prevalence of pulmonary embolism among patients hospitalized for syncope. N Engl J Med. 2016; 375:1524–1531.

88. Kearon C. Natural history of venous thromboembolism. Circulation. 2003; 107:I22–I30.

89. Varkul M, Robinson T, Ng E, Hyland R. Orthodeoxia and platypnea secondary to a patent foramen ovale despite normal right-sided cardiac pressures. Can Respir J. 2001; 8:105–107.

90. Sentjens RE, Houtman S, Meijerink MR, Konings TC. Emboli on the move. J Crit Care. 2010; 14:399–401.

91. Giorgi-Pierfranceschi M, Cattabiani C, Mumoli N, Dentali F. Abdominal pain as pulmonary embolism presentation, usefulness of bedside ultrasound: a report of two cases. Blood Coagul Fibrinolysis. 2017; 28:107–111.

92. Inouye SK. Delirium in older persons. N Engl J Med. 2006; 354:1157–1165.

93. Laack TA, Goyal DG. Pulmonary embolism: an unsuspected killer. Emerg Med Clin North Am. 2004; 22:961–983.

94. Søgaard KK, Schmidt M, Pedersen L, Horváth-Puhó E, Sørensen HT. 30-year mortality after venous thromboembolism: a population-based cohort study. Circulation. 2014; 130:829–836.

95. Carrascosa MF, Batán AM, Novo MF. Delirium and pulmonary embolism in the elderly. Mayo Clin Proc. 2009; 84:91–92.