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Acute Pulmonary Embolism: A concise review of diagnosis and management.
Intern Med J. 2018 Oct 15;:
Authors: Hepburn-Brown M, Darvall J, Hammerschlag G
Abstract
An acute Pulmonary Embolism (aPE) is characterised by occlusion of one or more pulmonary arteries. Physiological disturbance may be minimal, but often cardiac output decreases as the right ventricle attempts to overcome increased afterload. Additionally, ventilation-perfusion mismatches can develop in affected vascular beds, reducing systemic oxygenation. Incidence is reported at 50-75 per 100,000 in Australia and New Zealand, with 30- day mortality rates ranging from 0.5% to over 20%. Incidence is likely to increase with the aging population, increased survival of patients with co-morbidities that are considered risk factors and improving sensitivity of imaging techniques. Use of clinical prediction scores, such as the Wells score, has assisted in clinical decision making and decreased unnecessary radiological investigations. However, imaging (ie. CT-PA or ventilation-perfusion scans) is still necessary for objective diagnosis. Anti-coagulation remains the foundation of PE management. Haemodynamically unstable patients require thrombolysis unless absolutely contraindicated, while stable patient with RV dysfunction or ischemia should be aggressively anti-coagulated. Stable patients with no RV dysfunction can be discharge home early with anti-coagulation and review. However, treatment should be case dependent with full consideration of the patient's clinical state. Direct Oral Anti-Coagulants have become an alternative to Vitamin K Antagonists and are facilitating shorter hospital admissions. Additionally, duration of anti-coagulation must be decided by considering any provoking factors, bleeding risk and comorbid state. Patients with truly unprovoked or idiopathic PEs often require indefinite treatment, while in provoked cases it is typically 3 months with some patients requiring longer periods of 6 to 12 months This article is protected by copyright. All rights reserved.
PMID: 30324770 [PubMed - as supplied by publisher]