A 63-year-old man arrives in the emergency department with acute shortness of breath. His past medical history is remarkable for well-controlled hypertension. On admission, his heart rate is 113 bpm, oxygen saturation is 91%, and respiratory rate is 35 breaths/min. His blood pressure is 145/65 mm Hg. He underwent knee replacement surgery 15 days earlier. His physical examination is unremarkable, as are an electrocardiogram and chest radiograph. Computed tomography pulmonary angiography of the chest demonstrates large thrombi in the right and left main pulmonary arteries, extending into the lobar branches. His right-to-left ventricular ratio is markedly increased at 1.2, and troponin is elevated. Echocardiography performed at the bedside reveals moderate right ventricular hypokinesis and dilation. He is started on intravenous heparin and admitted to the intensive care unit.
Incidence of 300,000 to 600,000 events per year in the United States.1
Third leading cause of cardiovascular mortality after myocardial infarction and stroke.2
Overall in-hospital mortality of 4%.3
Most deaths that occur within 4 days of admission are attributable to the pulmonary embolism (PE).
Approximately half of deaths within 3 months of a PE are attributable to the PE, whereas the rest of the deaths most commonly occur due to cancer or underlying cardiopulmonary disease.
Approximately 25% to 35% of PEs present in the massive or submassive category.
Massive PE mortality ranges from 25% to 65%.4
Submassive PE mortality is 2% to 3%.5
Submassive PE clinical deterioration (progression to massive physiology and/or shock) of 5% to 6%.6,7
Low-risk PE mortality is <1%.4
For classification and terminology of PE, see Tables 29-1 and 29-2.4,8,9
| Clinical Presentation | American Heart Association Classification4 | European Society of Cardiology Classification8 |
|---|---|---|
| Hypotension (systolic blood pressure <90 mm Hg for 15 minutes, or requiring vasopressor support, or >40-mm Hg drop in systolic blood pressure) | Massive | High risk |
| Submassive | Intermediate riska
|
| No hypotension, right ventricular dysfunction | Low risk | Low risk |
| Parameter (each parameter earns 1 point) |
| Age >80 years |
| Cancer |
| Congestive heart failure or chronic obstructive pulmonary disease (1 item) |
| Heart rate >110 bpm |
| Systolic blood pressure <100 mm Hg |
| Oxygen saturation <90% |
Given that mortality varies by stratification, the following should be obtained if there is suspicion that that the patient is in a higher risk category:
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