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Nonoperative Treatment of Acute Pulmonary Embolism


Pulmonary embolism (PE) is a serious and potentially life-threatening condition afflicting a broad spectrum of the population. It has been reported that approximately 600,000 patients experience a PE episode each year in the United States. Mortality rate exceeds 15% in the first 3 months after diagnosis, surpassing that of myocardial infarction. The majority of deaths from acute PE result from right ventricular (RV) pressure overload and subsequent RV failure. As long as their RV dysfunction persists, these patients are at risk for proceeding into hemodynamic compromise, cardiogenic shock, and death. Acute PE represents a spectrum of clinical syndromes with a variety of prognostic implications based on three distinct categories: minor, submassive, and massive.

Risk Stratification

Patients with minor PE present with small clots in the distal pulmonary vessels, pleuritic chest pain, mild tachycardia, and possibly hemoptysis, with normal systemic arterial blood pressure and no evidence of right heart dysfunction. These patients have an excellent prognosis with therapeutic anticoagulation alone.

Patients with submassive PE present with thrombosis usually in one or both of the left and right pulmonary arteries, hemodynamic compensation, and maintenance of adequate systolic arterial blood pressure, albeit with of right RV dysfunction identified by one or more clinical signs detectable on physical examination, electrocardiography, biomarker tests, echocardiography, and chest computed tomography ( Box 1 ). These patients carry an increased risk for adverse events and early mortality.

BOX 1
Clinical Signs of Right Ventricular Dysfunction

Physical Examination

  • Tachycardia

  • Elevated jugular venous pressure (distention)

  • Right parasternal heave

  • Accentuated sound of pulmonic valve closure

Electrocardiography

  • Incomplete or complete right bundle branch block

  • T-wave inversion (in leads V 1 –V 4 )

  • S1Q3T3

  • Pseudoinfarction pattern (Qr) in V 1

Echocardiography

  • Right ventricular dilatation

  • Right ventricular hypokinesis

  • McConnell’s sign

  • Intraventricular septal bowing

  • Paradoxical septal motion toward the left ventricle

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