Massive pulmonary embolism with anterolateral ST-segment elevation: electrocardiogram limitations and the role of echocardiogram

Although acute pulmonary embolism (PE) may give rise to certain electrocardiographic (ECG) changes, most of these changes have low sensitivity and specificity and are of limited value alone in the diagnosis. Possible ECG changes with acute PE include S(1)Q(3)T(3) pattern, atrial tachyarrhythmias, incomplete right bundle-branch block, or negative T wave over right and midprecordial leads. Elevation of ST segment is a rare ECG manifestation with PE. We present a case of PE that went unrecognized in the emergency department (ED). The patient presented with anterior chest pain and dyspnea, and ECG showed ST elevation in V3 through V6. The differential diagnosis included acute coronary syndrome and acute pericarditis. Echocardiography revealed dilatation and dysfunction of right ventricle. Emergent computed tomographic pulmonary angiography showed bilateral pulmonary artery thrombosis and confirmed the diagnosis. Thrombolytic therapy with tissue plasminogen activator was initiated, and symptoms subsided dramatically. We proposed that the ST elevation in anterolateral leads might be the reciprocal changes of myocardial strain in the interventricular septum or right ventricle lateral wall. In a patient with such a critical condition and a confusing ECG, echocardiography played an important role in the diagnostic procedure, enabling prompt therapeutic intervention.     

Management of venous thromboembolism in the intensive care unit

Venous thromboembolism, manifested as either deep venous thrombosis or pulmonary embolism (PE), is a major cause of morbidity and mortality in patients admitted to the intensive care unit. Clinically, PE may present as massive thromboembolism associated with cardiogenic shock or may be asymptomatic, as may occur with anatomically small emboli without hemodynamic or respiratory compromise. The management of venous thromboembolism in the critically ill patient can be exceedingly complex. The main treatment objectives are the prevention of recurrent PE and, in case of hemodynamic compromise, definitive therapy for deep venous thrombosis or PE involving removal of thrombus. Prevention of recurrent PE is accomplished with anticoagulation and/or placement of an inferior vena cava filter. Definitive therapy involves thrombolysis and surgical or catheter embolectomy. Fluid and vasoactive therapy with norepinephrine may be indicated for refractory hypotension in patients with massive PE.     

Management of deep venous thrombosis and pulmonary embolism

The management of deep venous thrombosis (DVT) and pulmonary embolism (PE) is changing dramatically. The US Food and Drug Administration has approved outpatient treatment of DVT with the low-molecular-weight heparin enoxaparin as a bridge to warfarin. Warfarin use is improved by avoiding loading doses and by recognizing previously unappreciated interactions and potentiation with commonly used medications such as acetaminophen. The importance of isolated calf and upper-extremity venous thromboses has been validated, so that patients with these conditions routinely undergo anticoagulation. Risk stratification for PE is becoming more sophisticated because practitioners now assess right ventricular function (usually by echocardiography) instead of relying solely on systemic arterial blood pressure and heart rate to determine prognosis. Among patients with massive DVT or hemodynamically unstable PE, thrombolysis, thrombectomy, and embolectomy (often performed in an interventional angiography laboratory) are being used with increasing skill and improved outcomes.     

Diagnostic role of ED ultrasound in deep venous thrombosis and pulmonary embolism.

Proximal deep venous thrombosis (DVT), which may lead to pulmonary embolism (PE), is one of the serious and underrecognized causes of lower extremity pain and swelling. The diagnosis of DVT requires a confirmatory objective test because clinical signs and symptoms are unreliable. Assessment of thigh vein compressibility with real-time ultrasound is an accurate test for DVT that may be performed rapidly at the bedside. Although unproven, we propose that wider use of this test in the emergency department by emergency physicians might increase the diagnosis of DVT, prevent PE, and reduce utilization of other more costly and invasive diagnostic tests. Evaluation of DVT by compression ultrasound may also be incorporated in the diagnostic workup of suspected PE. In the case of a nondiagnostic ventilation/perfusion scan, demonstration of proximal DVT by ultrasound represents a likely source of PE and an indication for anticoagulation, eliminating the need for pulmonary angiography. In the critically ill patient whose presentation is consistent with massive PE, one rapid approach to the diagnosis may be to combine transthoracic echocardiography with lower extremity ultrasound.     

超声心动图急性肺栓塞溶栓治疗的评估

目的应用超声心动图技术观察急性肺栓塞患者溶栓抗凝治疗前后肺动脉栓子、右心结构及收缩功能的改变。方法前瞻性非随机对照研究,对2002年12月至2006年4月间经肺动脉CT或肺血管造影证实的30例急性肺栓塞患者行溶栓治疗,应用经胸超声心动图观察治疗前、治疗后24～30h、1个月的肺动脉栓子、主肺动脉及其分支内径、右房室内径,右室前壁运动幅度、右室舒张末期容积、右室射血分数,三尖瓣返流、肺动脉收缩压等指标。结果30例急性肺动脉栓塞患者溶栓治疗24～30h后右房室结构明显改善,表现为右房长径及横径、右室前后径及横径、主肺及右肺动脉内径、右室舒张末期容积与治疗前比较明显回缩(P<0.01),右室前壁运动幅度、右室射血分数有所增加(P<0.01),肺动脉收缩压明显下降(P<0.01);治疗后1个月后右房室大小、主肺及右肺动脉内径、右室舒张末期容积、右室前壁运动幅度及肺动脉收缩压等仍有恢复(P<0.05或P<0.01)。5例患者主肺动脉和/或右、左肺动脉内检出栓子,溶栓后栓子逐渐消失。结论超声心动图可动态、实时、无创评价急性肺动脉栓塞溶栓治疗效果,尤对血栓的溶解、右房室结构、右室超负荷及肺动脉高压的变化有独到的价值。     

Thrombolytic therapy and outcome of patients with an acute symptomatic pulmonary embolism

Background:  While the primary therapy for most patients with a pulmonary embolism (PE) consists of anticoagulation, the efficacy of thrombolysis relative to standard therapy remains unclear. Methods:  In this retrospective cohort study of 15 944 patients with an objectively confirmed symptomatic acute PE, identified from the multicenter, international, prospective, Registro Informatizado de la Enfermedad TromboEmbólica (RIETE registry), we aimed to assess the association between thrombolytic therapy and all‐cause mortality during the first 3 months after the diagnosis of a PE. After creating two subgroups, stratified by systolic blood pressure (SBP) (< 100 mm Hg vs. other), we used propensity score‐matching for a comparison of patients who received thrombolysis to those who did not in each subgroup. Results:  Patients who received thrombolysis were younger, had fewer comorbid diseases and more signs of clinical severity compared with those who did not receive it. In the subgroup with systolic hypotension, analysis of propensity score‐matched pairs (n = 94 pairs) showed a non‐statistically significant but clinically relevant lower risk of death for thrombolysis compared with no thrombolysis (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.36–1.46; P = 0.37). In the normotensive subgroup, analysis of propensity score‐matched pairs (n = 217 pairs) showed a statistically significant and clinically meaningful increased risk of death for thrombolysis compared with no thrombolysis (OR 2.32; 95% CI, 1.15–4.68; P = 0.018). When we imputed data for missing values for echocardiography and troponin tests in the group of normotensive patients, we no longer detected the increased risk of death associated with thrombolytic therapy. Conclusions:  In normotensive patients with acute symptomatic PE, thrombolytic therapy is associated with a higher risk of death than no thrombolytic therapy. In hemodynamically unstable patients, thrombolytic therapy is possibly associated with a lower risk of death than no thrombolytic therapy. However, study design limitations do not imply a causal relationship between thrombolytics and outcome.     

中危（次大面积）急性肺栓塞患者是否需要溶栓治疗

中危（次大面积）急性肺栓塞患者是否需要溶栓治疗已经争论了很多年。中危肺栓塞患者具有较高的死亡风险。因此,有人建议给予中危肺栓塞患者溶栓治疗,溶栓治疗可以更快地溶解血栓,从而降低中危肺栓塞患者的病死率。但也有研究表明,与单纯抗凝治疗比较,溶栓治疗不能进一步降低中危急性肺栓塞患者的病死率和复发率,且并发出血率较高。该文就中危急性肺栓塞溶栓治疗的有效性及安全性作一综述。     

Hospital-based management of acute ischemic stroke following intravenous thrombolysis

Timely administration of proven therapies remains the primary goal in acute stroke care. Following reperfusion therapy with intravenous thrombolysis, medical and neurological complications may develop in the hospitalized patient with acute ischemic stroke. Medical complications may include deep venous thrombosis, pulmonary embolism, aspiration, systemic infections and neuropsychiatric disturbances. Neurologic complications may include symptomatic intracranial hemorrhage, cerebral edema with elevated intracranial pressure, and post-stroke seizures. Early initiation of preventative strategies and proper management of common complications may improve both short-term and long-term outcomes. Here we review evidence-based management strategies for hospitalized acute ischemic stroke patients following intravenous thrombolysis.     

D-二聚体阴性肺栓塞患者的临床特点

目的 归纳总结D-二聚体阴性(D-二聚体＜0.5μg/mL)的肺栓塞患者的临床特点,从而提高肺栓塞诊断准确率、降低肺栓塞的病死率。方法 对南京医科大学第一附属医院2006年1月至2009年12月收治的D-二聚体阴性的疑似肺栓塞患者的危险因素、临床特征及辅助检查进行回顾分析,将16例最终确诊肺血栓栓塞症患者与同期排除肺栓塞的41例疑似患者的临床特点进行比较,采用t检验及四格表Fisher确切概率法比较各组间临床表现、生命体征及辅助检查结果的差异。结果 D-二聚体阴性的肺栓组与非病例组相比,既往有VTE病史、有近期手术史者更易于发病,胸闷、呼吸困难常见,病例组呼吸频率高于对照组,病例组下肢水肿较对照组多见,心电图典型ECG SI QⅢTⅢ改变多见。结论D-二聚体作为急性肺栓塞筛选检查,其阴性预测值较高,但当患者出现进行性呼吸困难、下肢水肿、既往有VTE病史、有近期手术史、心电图出现SIQⅢTⅢ改变时,即使D-二聚体阴性,临床工作者也需引起重视,必要时可考虑进一步检查以排查有无肺栓塞。     

下腔静脉滤器置人应用于下肢深静脉血栓形成的临床分析

目的探讨下腔静脉滤器（VCF）置入联合抗凝溶栓治疗下肢深静脉血栓形成（DVT）的效果及防治肺动脉栓塞的意义。方法回顾性分析2009年1月至2011年9月我院收治的DVT患者．115例,选择27例适合行VCF置入的患者,在数字减影血管造影术下行VCF置入,术后给予溶栓、抗凝等治疗。结果27例患者下腔静脉内均成功置入VCF,经溶栓、抗凝后患肢肿胀明显消退,术后无肺栓塞及滤器置入相关并发症发生。结论VCF置入联合抗凝溶栓治疗DVT疗效好且安全,VCF置入可有效预防下肢深静脉血栓患者肺栓塞的发生。     

Diagnostic utility of echocardiography in patients with suspected pulmonary embolism

The aim of this study was to investigate the clinical utility of echocardiography in the diagnosis of pulmonary embolism (PE). For this, we enrolled 162 patients with suspected PE in a prospective study. We evaluated the sensitivity and specificity of right ventricular dilatation, the Doppler evidence of pulmonary hypertension, and their possible associations. We also calculated the number of lung-scan angiography procedures avoided and the number of patients unnecessarily treated when echocardiography was included in the diagnostic work-up. The sensitivity and specificity of echocardiography ranged between 29 and 52% and between 96% and 87%, respectively. Adding echocardiography to the diagnostic strategy for PE would avoid about 12 to 28% of lung-scan angiography procedures, but would cause inappropriate treatment of 4 to 14% of all treated patients. The clinical utility of echocardiography in the diagnosis of PE is limited. The reduction in the number of standard diagnostic procedures obtained through its use would be counterbalanced by an excess of patients inappropriately treated.     

Management of venous thromboembolism: an update

Venous thromboembolism (VTE), which constitutes pulmonary embolism and deep vein thrombosis, is a common disorder associated with significant morbidity and mortality. Landmark trials have shown that direct oral anticoagulants (DOACs) are as effective as conventional anticoagulation with vitamin K antagonists (VKA) in prevention of VTE recurrence and associated with less bleeding. This has paved the way for the recently published guidelines to change their recommendations in favor of DOACs in acute and long-term treatment of VTE in patients without cancer. The recommended treatment of VTE in cancer patients remains low-molecular-weight heparin. The initial management of pulmonary embolism (PE) should be directed based on established risk stratification scores. Thrombolysis is an available option for patients with hemodynamically significant PE. Recent data suggests that low-risk patients with acute PE can safely be treated as outpatients if home circumstances are adequate. There is lack of support for use of inferior vena cava filters in patients on anticoagulation. This review describes the acute, long-term, and extended treatment of VTE and recent evidence on the management of sub-segmental PE.     

Patients with inferior vena caval filters should receive chronic thromboprophylaxis

A 32-year-old man with testicular carcinoma is diagnosed with an acute left leg deep venous thrombosis (DVT) during his fourth cycle of combination chemotherapy. Because of anticipated moderate to severe thrombocytopenia, anticoagulation is initially avoided and an inferior vena cava (IVC) filter is placed to prevent pulmonary embolism (PE). After completion of all chemotherapy he is deemed to be in remission and anticoagulation is begun. The optimal duration of anticoagulation in this patient is pondered.     

双源CT一站式扫描诊断急性肺栓塞与深静脉血栓

目的 评价双源CT(DSCT)一站式扫描对急性肺栓塞(PE)及深静脉血栓(DVT)的诊断价值。方法 采用DSCT对56例临床疑诊急性PE患者先行肺动脉成像(CTPA),间隔120~180 s后再行深静脉成像(CTV)。利用MPR和MIP观察PE和DVT分布情况。56例中,12例于CTPA检查发现PE后接受DSA检查。以血管节段为单位,记录双源CT和DSA对PE和DVT的诊断结果,并与DSA检查结果进行比较。结果 12例PE患者中发现DVT 11例,CTPA对肺段及亚段动脉PE的检出率明显高于DSA(χ²=8.34、92.65,P均<0.01),对肺叶动脉及以上级别血管PE的检出率与DSA差异无统计学意义(P均>0.05)。CTV对DVT的检出率与DSA相比差异无统计学意义(χ²=0.667,P=0.414)。以DSA为金标准,CTV评价DVT的敏感度、特异度、准确率分别为92.16%(47/51)、96.49%(55/57)、94.44%(102/108)。结论 双源CT一站式扫描可同时准确地诊断急性PE及DVT。     

Short-term prognosis of pulmonary embolism

Summary.  Risk stratification tools that accurately quantify the prognosis of patients with pulmonary embolism (PE) may be useful in guiding medical decision making. Prospective studies demonstrated that clinical factors, echocardiographic right ventricular dysfunction, and cardiac biomarkers (troponins, brain natriuretic peptides) are independent predictors of short-term mortality in patients with PE. The presence of systemic hypotension or shock carries the highest risk of death, and thrombolysis is usually indicated. Among hemodynamically stable patients, clinical prognostic models, echocardiography, and biomarkers accurately identify low-risk patients with PE who are potential candidates for less costly outpatient care. However, the practical use of these prognostic measures is currently limited by the lack of studies demonstrating a positive impact on patient care. The benefit of risk stratification strategies based on clinical prognostic models, echocardiography, and cardiac biomarkers should be demonstrated in prospective studies before their implementation as decision aid to guide initial treatment can be recommended.     

An analysis of the diagnostic methods for acute pulmonary embolism

In spite of numerous sophisticated investigative procedures, acute pulmonary embolism (PE) is very frequently misdiagnosed. In order to improve the diagnostic approach to PE, the sensitivity and specificity of the commonly used methods were reviewed in a group of 421 patients with angiographically proved PE without associated cardio-pulmonary disease. The specificity of diagnostic procedures was, by decreasing order: positive pulmonary angiography (to affirm) = negative perfusion lung scan (to eliminate) > chest X-ray clinical symptoms, positive perfusion lung scan, ECG, blood gas, serum enzymes.     

急性肺栓塞CT肺动脉成像的研究进展

目前,CT肺动脉成像（CTPA）被认为是临床诊断急性肺栓塞（PE）的“金标准”。CTPA为诊断急性外周性PE提供了多方面的依据。但CTPA诊断急性外周性PE仍存在较大困难。目前CT辐射剂量及对比剂负荷为研究热点。本文对急性PE的CTPA诊断（尤其是外周性PE）、预后评估、CTPA技术进展等进行综述。     

C-反应蛋白对急性肺栓塞预后的评估

目的 探讨血浆C-反应蛋白(CRP)水平对评估急性肺栓塞患者预后的价值.方法 56例急性肺栓塞患者,通过螺旋CT、肺动脉造影(CTPA)、磁共振显像(MRI)、肺动脉造影确诊,入院后均行CRP、心电图(ECG)、超声心动图(UCG)、动脉血气分析等检查.结果 CRP≥10 mg/L共24例,其中大面积肺栓塞12例(50.0%),次大面积11例(45.8%),小面积栓塞1例(4.2%),死亡6例(25.0%);UCG示右心室功能不全24例(100.0%),肺动脉高压24例(100.0%),心电图示右心室负荷过重20例(83.3%),PaO2<60mm Hg 22例(91.7%);晕厥8例(33.3%),心源性休克9例(37.5%).CRP<10 mg/L者32例,其中大面积肺栓塞3例(9.4%),次大面积6例(18.8%),小面积23例(71.8%),死亡1例(6.3%);UCG示右心室功能不全13例(40.6%),肺动脉高压16例(50.0%),心电图示右心室负荷过重15例(46.9%),PaO2<60mm Hg 11例(34.4%);晕厥2例(6.3%),心源性休克4例(12.5%).2组比较,大面积栓塞发生率、病死率、次大面积栓塞发生率差异均有统计学意义(P<0.01或P<0.05),辅助检查右心室功能不全、肺动脉高压、右心室负荷过重、PaO2<60 mm Hg发生率差异均有统计学意义(P均<0.01),症状和体征中晕厥、心源性休克发生率差异均有统计学意义(P均<0.05).结论 CRP可作为急性肺栓塞患者的预后指标,可以帮助明确危险分层,指导治疗.     

Bolus injection of thrombolytic agents during cardiopulmonary resuscitation for massive pulmonary embolism

Thrombolytic therapy has proved to be efficacious in the treatment of massive and fulminant pulmonary embolism (PE), but thrombolysis has been considered as contraindicated during cardiopulmonary resuscitation (CPR). This review on the administration of thrombolytic agents in patients who have suffered massive PE necessitating CPR summarises 14 anecdotal reports and three case series involving 34 patients. The case series revealed an overall initial survival rate of 55–100% following bolus administration of thrombolytic agents. In general, bleeding complications were managed conservatively. The establishment of the diagnosis may be feasible using echocardiography or bedside angiography during CPR. However, therapeutic measures should be taken without delay; the patient's history and the clinical picture may thus be the only diagnostic criteria. Even where myocardial infarction is misinterpreted as PE during CPR, bolus injection of a thrombolytic agent can be an appropriate therapeutic option. An alternative may be mechanical catheter fragmentation of the thrombus with subsequent local thrombolysis. Surgery may be restricted to hospitals with ready access to extracorporeal circulation. We conclude that early administration of thrombolytic agents during PE necessitating CPR may help to reduce mortality. We favour the administration of urokinase (2– to 3 000 000-U bolus) or rt-PA.     

Direct oral anticoagulants as alternative treatment options for the effective long-term treatment of patients with pulmonary embolism in primary care: a review

Abstract

Pulmonary embolism (PE) represents a potentially life-threatening venous thromboembolic disorder, and prompt treatment is vital to prevent early mortality. However, diagnosis of PE is complicated by the range of signs and symptoms with which it presents. Clinical risk scores, imaging techniques, and laboratory tests are recommended in clinical guidelines to aid diagnosis, and risk stratification strategies can be used to inform treatment decisions. Long-term anticoagulation is key to avoid the risk of later complications of acute PE, such as recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension. Rivaroxaban is a direct oral anticoagulant that has been approved for the treatment of PE (and deep vein thrombosis) and prevention of recurrent venous thromboembolism; other direct oral anticoagulants have undergone phase III trials for these indications. These agents may provide advantages over traditional anticoagulants, such as vitamin K antagonists, because they are administered at fixed doses and do not require routine coagulation monitoring. These advantages may improve patient adherence and aid general practitioners by simplifying long-term management of PE in daily primary care.