Pulmonary embolism: differences in presentation between older and younger patients

BACKGROUND: the incidence of pulmonary embolism increases with age but the 'classical' presentation of acute pulmonary embolism may not occur in older persons. OBJECTIVES: to compare the clinical presentation of younger and older patients with acute pulmonary embolism. DESIGN: retrospective identification of 60 consecutive cases of spiral computed tomography confirmed acute pulmonary embolism over a 3-year period, with blinded review of radiological films and electrocardiographs, and analysis of clinical presentation. SETTING: a district general hospital serving a population of 200,000 people. SUBJECTS: 31 younger and 29 older patients with acute pulmonary embolism. RESULTS: older persons less often complained of pleuritic chest pain (P < 0.02), particularly as their primary presenting complaint (P < 0.002). Twenty-four percent of older but just 3% of younger persons presented with collapse (P < 0.02), despite similar proportions of central and peripheral emboli in the two groups. Older persons were more often cyanosed (P = 0.05) and hypoxic (P < 0.04) than younger persons but there were no significant differences with respect to heart rate, respiratory rate or mean arterial blood pressure. CONCLUSIONS: older people present atypically with acute pulmonary embolism, potentially leading to delays in diagnosis and initiation of treatment. Collapse is a particularly important symptom of acute pulmonary embolism in older persons, even in the absence of pain.     

Diagnosing pulmonary embolism: a comparison of clinical probability scores

Pulmonary embolism (PE) is a major cause of community and in‐hospital mortality. This study aimed to compare the performance of the British Thoracic Society (BTS) score to the Wells’ score in diagnosing PE. Data from two separate prospective diagnostic PE studies were analysed. All patients underwent gold standard investigation to determine the presence or absence of PE, together with a 3‐month follow‐up. The posttest prevalence of PE was compared using both scores and the receiver operating characteristic (ROC) curves. Seven hundred and seventy‐nine patients were consented and investigated for PE. In patients with pleuritic chest pain, respiratory rate <20 breaths/min and absence of dyspnoea, 4·0% [95% confidence interval (CI) 1·9–7·9%] had PE. The BTS score allocated 463/779 patients as low probability, compared to 565/779 according to the Wells’ score. Both scores identified a low risk group in the Manchester Investigation of Pulmonary Embolism Diagnosis cohort, however the BTS low probability group in the Thromboembolism Assessment and Diagnosis study had a prevalence of 9·7% (95% CI 5·8–15·9%). For the BTS score, the areas under the ROC curves were 0·67 (95% CI 0·61–0·72) and 0·71 (95% CI 0·61–0·75). For the Wells’ score these were 0·76 (95%CI 0·71–0·81) and 0·68 (95%CI 0·64–0·73). Given the lack of BTS validation studies to date, the Wells’ score appears to be the safer assessment option.     

Pulmonary embolism as a cause of cardiac arrest: presentation and outcome

BACKGROUND: Pulmonary embolism (PE) is a possible noncardiac cause of cardiac arrest. Mortality is very high, and often diagnosis is established only by autopsy. METHODS: In a retrospective study, we analyzed clinical presentation, diagnosis, therapy, and outcome of patients with cardiac arrest after PE admitted to the emergency department of an urban tertiary care hospital. RESULTS: Within 8 years, PE was found as the cause in 60 (4.8%) of 1246 cardiac arrest victims. The initial rhythm diagnosis was pulseless electrical activity in 38 (63%), asystole in 19 (32%), and ventricular fibrillation in 3 (5%) of the patients. Pronounced metabolic acidosis (median pH, 6.95, and lactate level, 16 mmol/L) was found in most patients. In 18 patients (30%), the diagnosis of PE was established only postmortem. In 42 (70%) it was diagnosed clinically, in 24 of them the diagnosis of PE was confirmed by echocardiography. In 21 patients, 100 mg of recombinant tissue-type plasminogen activator was administered as thrombolytic treatment, and 2 (10%) of these patients survived to hospital discharge. Comparison of patients of the thrombolysis group (n = 21) with those of the nonthrombolysis group (n = 21) showed a significantly higher rate of return of spontaneous circulation (81% vs 43%) in the thrombolysis group (P=.03). CONCLUSIONS: Mortality related to cardiac arrest caused by PE is high. Echocardiography is supportive in determining PE as the cause of cardiac arrest. In view of the poor prognosis, thrombolysis should be attempted to achieve return of spontaneous circulation and probably better outcome.     

Pulmonary embolism,part I: Epidemiology,risk factors and risk stratification,pathophysiology, clinical presentation,diagnosis and nonthrombotic pulmonary embolism

Pulmonary embolism is an important clinical entity with considerable mortality despite advances in diagnosis and treatment. In the present article, the authors offer a comprehensive review focused mainly on epidemiology, risk factors, risk stratification, pathophysiological considerations and clinical presentation. Diagnosis based on assessment of clinical likelihood, electrocardiography, chest x-ray, D-dimer levels, markers of myocardial injury and overload, and blood gases is discussed in detail. Special attention is devoted to the clinical use of computed tomography, pulmonary angiography and echocardiography in the setting of pulmonary embolism.     

Paradoxical embolism: clinical presentation, diagnostic strategies, and therapeutic options

Thirty cases of paradoxical embolism are reviewed to consolidate clinical presentations and common predisposing factors. The presence of patent foramen ovale in the great majority of these patients in association with maneuvers that transiently elevate right atrial pressure is emphasized in relation to the pathophysiology of the disorder. Contrast echocardiography with provocative maneuvers such as Valsalva and cough are discussed and treatment options highlighted. The underdiagnosis of paradoxical embolism is discussed, and its potential importance in other more common vascular diseases addressed.     

Pulmonary embolism

Pulmonary embolism (PE) is a common illness that can cause death and disability. It is difficult to detect because patients present with a wide array of symptoms and signs. The clinical setting can raise suspicion, and certain inherited and acquired risk factors predispose susceptible individuals. D-dimer concentration in blood is the best laboratory screening test, and chest CT has become the most widespread imaging test. Treatment requires rapid and accurate risk stratification before haemodynamic decompensation and the development of cardiogenic shock. Anticoagulation is the foundation of therapy. Right-ventricular dysfunction on echocardiography and higher than normal concentrations of troponin identify high-risk patients who might need escalation of therapy with thrombolysis or embolectomy even if the blood pressure is normal on presentation. When patients are admitted to medical wards or when patients undergo surgery, their physicians should prescribe prophylactic measures to prevent PE. After hospital discharge, prophylaxis should continue for about a month for patients at high risk of thromboembolism.     

Pulmonary embolism

It is estimated that 600,000 or more symptomatic episodes of pulmonary embolism occur each year in the United States, and this diagnosis is one that may often be missed. This article provides an appraisal of currently used diagnostic procedures, including laboratory tests, arterial oxygen tension, chest radiography, electrocardiography, lung scanning, and selective pulmonary angiography, and examines the available therapeutic options and their indications.     

Pulmonary embolism

The incidence and mortality of acute pulmonary embolism (PE) remain ill defined, particularly in the setting of the emergency department. However, high-risk groups can be identified based on medical conditions known to predispose patients to venous thrombosis. Recent research into the physiologic regulation of coagulation and thrombolysis reveals that recurrent venous thrombosis and PE may be caused by heritable deficiencies and abnormalities of plasma proteins. To decide among options for evaluation and treatment of patients suspected of PE, physicians combine clinical assessment with patterns observed on radionuclide ventilation-perfusion (V/Q) scans. However, the prevalence of PE among patients with "low probability" V/Q scans suggests that current physician behavior may be imprudent. Heparin anticoagulation continues to be standard therapy for acute PE, but newer clot-specific thrombolytic drugs may offer superior benefits with acceptable complication rates in carefully selected patients.     

Influence of age on clinical presentation of acute pulmonary embolism

The aims of this study were to compare the clinical features of patients with pulmonary embolism (PE) and patients in whom the initial suspected diagnosis was not confirmed by the complementary studies and to determine the possible clinical differences among patients with PE according to age. A retrospective review of the charts of a group of patients with PE (n, 96) and another without PE (n, 96) was carried out. The patients with PE over 65 years of age (n, 64) were compared with those under 66 years of age (n, 32). The variables related to PE were absence of known heart disease, duration of symptoms ≤2 days, pleuritic chest pain, absence of cough, pCO₂ <4.8 kPa (36 mmHg), and normal chest X-ray. The variables associated with the existence of PE in patients over 65 years of age, when contrasted with younger patients, were female sex, absence of pleuritic chest pain, abnormal chest X-ray, hypoxemia (pO₂ < 8.7 kPa (65 mmHg) and absence of S1Q3T3 pattern in ECG.The duration of symptoms and the presence of hypocapnia, pleuritic chest pain, and normal chest X-ray may lead to the suspicion of PE. Pleuritic pain and S1Q3T3 pattern are less commonly found in old patients with PE.     

Pulmonary embolism in the elderly: clinical, instrumental and laboratory aspects

OBJECTIVE: To focus on diagnostic and therapeutic problems of pulmonary embolism in the elderly. METHODS: Retrospective analysis of 5 years of clinical, instrumental, and laboratory data (collected at the time of hospital admission) for patients 65 years and older with pulmonary embolism proven by a high-probability scintigraphic lung scan or necropsy. Sixty-eight patients, 46 females and 22 males, 78.61 +/- (SD) 7.71 years old, were enrolled in the study. RESULTS: Dyspnea, chest pain, tachycardia, and tachypnea were the most common symptoms and signs; they were present alone or in combination in all patients. Bed rest over 4 days was found in 65% of the patients and deep vein thrombosis in the leg in 35%. Only 7 patients were on anticoagulant therapy which was likely to reduce the incidence of pulmonary embolism. The mortality was 29.5%. Major bleeding due to anticoagulant therapy was observed in 4.4% of the patients; 1 case was fatal. Sinus tachycardia, ST segment and T wave abnormalities in anterior leads, and incomplete bundle branch block were the most frequent electrocardiographic findings. Chest X-ray was normal in 19.5% of the patients and compatible with pulmonary embolism in 10%. A transthoracic two-dimensional echocardiogram was abnormal in 74% of the cases, with involvement of the right ventricle in the majority of them. Many patients had laboratory parameters within the normal range. The value of the latex agglutination D-dimer assay was less than the cutoff value of 500 microg/l in 16% of the patients. Hypoxemia and a high alveolar-arterial oxygen gradient were the most frequent aspects of the arterial blood gas analysis. Respiratory alkalosis was observed in only one third of the patients. CONCLUSIONS: Pulmonary embolism is often underdiagnosed in the elderly. Clinical, instrumental, and laboratory findings are nonspecific. Only acute suspicion can increase the number of diagnoses, reduce the time to diagnosis, and improve the prognosis.