de pulmòn (TEP):
sobre diagnóstico y tratamiento
1: Arch Intern Med 2002 Apr 8;162(7):747-56
Plasma D-dimers in the diagnosis of venous
Kelly J, Rudd A, Lewis RR, Hunt BJ.
SpR in Elderly Care/GIM, Elderly Care Dept, c/o
Alexandra Ward, North Wing, Ninth Floor, St Thomas' Hospital, Lambeth
Palace Road, Lambeth, London SE1 7EH, England.
Clinical suspicion for venous thromboembolism
(VTE) mandates objective testing to confirm or exclude the diagnosis.
However, current imaging modalities are imperfect because of a small but
important risk of complications with invasive techniques or limited
sensitivity with noninvasive ones. A diagnostic tool for VTE is needed
that is noninvasive and highly accurate, allowing immediate treatment
decisions to be made in most cases. Plasma D-dimers (D-ds), specific
cross-linked fibrin derivatives, partially fulfill these criteria in that
they are sensitive markers for thrombosis but lack specificity. They
therefore cannot be used to make a positive diagnosis of VTE; however,
they generally have high negative predictive value and are useful as an
exclusionary test, a potentially important role given that VTE is
eventually ruled out in most patients investigated. Clinical management
studies are clarifying the role of D-ds in the diagnostic paradigm of VTE:
negative ultrasound and D-d findings obviate the need for serial imaging
in suspected deep vein thrombosis, and anticoagulant therapy can be safely
withheld in patients with non-high clinical suspicion for pulmonary
embolism and non-high probability ventilation perfusion scan if D-d test
results are negative. More recently, the combination of a negative
SimpliRED (AGEN Biomedical Ltd, Brisbane, Australia) D-d result and low
clinical suspicion derived using a formal scoring system has been shown to
exclude deep vein thrombosis and pulmonary embolism and to obviate the
need for imaging. Several different D-d assays are now available, and
clinicians should be aware of the performance characteristics of the test
used before incorporation into diagnostic algorithms as these will differ
between assays, and the results of clinical management studies cannot
necessarily be safely extrapolated to assays other than those specifically
evaluated. If alternative assays are to be substituted, these should
consistently have been shown to possess equivalent or greater sensitivity.
2: Postgrad Med 2002 Mar;111(3):27-8, 33-4, 39-40 passim [Texto
intervention in massive pulmonary embolism. A guide to diagnosis and
triage for the critical first hour.
Department of Medicine, Medical College of
Georgia School of Medicine, Section of Pulmonary and Critical Care
Medicine, BBR-5513, 1120 15th St, Augusta, GA 30912-3135, USA.
The diagnosis of massive pulmonary embolism
should be considered expeditiously in all patients with unexplained
hypotension, syncope, cardiac arrest, or hypoxemic respiratory failure.
The presence of right ventricular overload on physical examination or
electrocardiogram is an especially important clue. Depending on local
expertise and the patient's stability, V/Q scanning, CT angiography,
echocardiography, and right heart catheterization can be useful in
establishing a diagnosis of pulmonary embolism. Supportive treatment
includes oxygen, vasoactive medicines, and sometimes fluids. Although
heparin is important in nearly all patients, 70% to 80% of patients also
require an IVC filter, thrombolysis, or embolectomy.
3: Clin Radiol
validity of a normal pulmonary angiogram in patients with suspected
pulmonary embolism--a critical review.
van Beek EJ, Brouwerst EM, Song B, Stein PD,
Section of Academic Radiology, Royal Hallamshire
Hospital, Sheffield, UK. firstname.lastname@example.org
AIM: To determine the validity of a normal
pulmonary angiogram in the exclusion of pulmonary embolism (PE), based on
the safety of withholding anticoagulant therapy in patients with a normal
pulmonary angiogram. MATERIALS AND METHODS: A review of English reports
published between 1965 and April 1999 was carried out. Eligible articles
described prospective studies in patients with suspected PE and a normal
pulmonary angiogram, who remained untreated and were followed-up for a
minimum of 3 months. Articles were evaluated by two authors, using
pre-defined criteria for strength of design. End points consisted of fatal
and non-fatal recurrent thromboembolic events. A sensitivity analysis was
performed, by removing one study at a time from the overall results and by
comparing pre- and post-1990 publications. RESULTS: Among 1050 patients in
eight articles included in the analysis, recurrent thromboembolic events
were described in 18 patients (1.7% 95% CI: 1.0-2.7%). These were fatal in
three patients (0.3% 95% CI: 0.02-0.7%). The recurrence rate of PE
decreased from 2.9% (95% CI: 1.4-6.8%) before 1990 to 1.1% (95% CI:
0.5-2.2%) after 1990. CONCLUSION: It would appear that the ability to
exclude PE by angiography has improved over the years, as indicated by
recurrence rate of PE. The low recurrence rate of PE supports the validity
of a normal pulmonary angiogram for the exclusion of PE.
4: Chest 2002
pulmonary embolism: review of a pathophysiologic approach to the golden
hour of hemodynamically significant pulmonary embolism.
Department of Medicine, University of Wisconsin
Hospitals & Clinics, Madison, WI 53792, USA. email@example.com
Major pulmonary embolism (PE) results whenever
the combination of embolism size and underlying cardiopulmonary status
interact to produce hemodynamic instability. Physical findings and
standard data crudely estimate the severity of the embolic event in
patients without prior cardiopulmonary disease (CPD) but are unreliable
indicators in patients with prior CPD. In either case, the presence of
shock defines a threefold to sevenfold increase in mortality, with a
majority of deaths occurring within 1 h of presentation. A rapid
integration of historical information and physical findings with readily
available laboratory data and a structured physiologic approach to
diagnosis and resuscitation are necessary for optimal therapeutics in this
"golden hour." Echocardiography is ideal because it is
transportable, and is capable of differentiating shock states and
recognizing the characteristic features of PE. Spiral CT scanning is
evolving to replace angiography as a confirmatory study in this
population. Thrombolytic therapy is acknowledged as the treatment of
choice, with embolectomy reserved for those in whom thrombolysis is
Mayo Clin Proc 2002
after withholding anticoagulation from patients with suspected acute
pulmonary embolism and negative computed tomographic findings: a cohort
Swensen SJ, Sheedy PF 2nd, Ryu JH, Pickett DD,
Schleck CD, Ilstrup DM, Heit JA.
Department of Radiology, Mayo Clinic, Rochester,
Minn 55905, USA.
OBJECTIVE: To determine the outcome of
withholding anticoagulation from patients with suspected acute pulmonary
embolism in whom computed tomographic (CT) findings are interpreted as
negative for pulmonary embolism. PATIENTS AND METHODS: This retrospective
cohort study included 1512 consecutive patients referred from August 7,
1997, to November 30, 1998, for CT because of clinically suspected acute
pulmonary embolism. All patients were examined by electron beam CT, and
scanning was performed in a cephalocaudad direction from the top of the
aortic arch to the base of the heart with 3-mm collimation, 2-mm table
incrementation, and an exposure time of 0.2 second (130 peak kV, 620 mA,
and standard reconstruction algorithm). Contrast material was infused at a
rate of 3 to 4 mL/s through an antecubital vein with an automated
injector. Findings on CT were interpreted as either positive or negative.
The main outcome measures were deep venous thrombosis, pulmonary embolism,
and vital status within 3 months after the CT scan and the cause of death
based on medical record review, mailed patient questionnaires, and
telephone interviews. RESULTS: In 1010 patients (67%) CT scans were
interpreted as negative for acute pulmonary embolism. Seventeen patients
were excluded because they received anticoagulation. Of the remaining 993
patients, deep venous thrombosis or pulmonary embolism developed in 8; 118
patients died, 3 of pulmonary embolism. Nineteen patients were known to be
alive, but additional clinical information could not be obtained. The
3-month cumulative incidence of overall deep venous thrombosis or
pulmonary embolism was 0.5% (95% confidence interval, 0.1%-1.0%) and of
fatal pulmonary embolism, 0.3% (95% confidence interval, 0.0%-0.7%).
CONCLUSIONS: The incidence of (1) overall deep venous thrombosis or
pulmonary embolism or (2) fatal pulmonary embolism among patients with
suspected acute pulmonary embolism, negative CT results, and no other
evidence of venous thromboembolism is low. Withholding anticoagulation in
these patients appears to be safe.
6: Hosp Med
venous thromboembolism: enoxaparin.
Haemophilia Centre and Haemostasis Unit, Royal
Free and University College Medical School, Royal Free Campus, London NW3
This article reviews the developments that have
occurred in the treatment of venous thromboembolism during the last
decade, with emphasis on the establishment of low molecular weight heparin
as a therapeutic agent of proven efficacy and examines the evidence that
supports the movement from inpatient to outpatient hospital management of
7: N Engl J Med 2001 Nov 15;345(20):1465-72
thromboembolic pulmonary hypertension.
Fedullo PF, Auger WR, Kerr KM, Rubin LJ.
Department of Medicine, University of
California, San Diego, Medical Center, La Jolla 92037-1300, USA.
8: Anesthesiol Clin North America
for suspected pulmonary embolism.
Capan LM, Miller SM.
Department of Anesthesiology, New York
University School of Medicine, Bellevue Hospital Center, New York, New
York, USA. firstname.lastname@example.org
It is fortunate that serious embolic phenomena
are uncommon because, with the exception of neurosurgery in the sitting
position and cardiac surgery, thoracic echocardiography and the precordial
Doppler device, the most sensitive indicators of embolism, are seldom
used. Vigilance is required of the anesthesiologist to recognize the rapid
fall in end-tidal PCO2, the usual first indicator of a clinically
significant PE. Any sudden deterioration in the patient's vital signs
should include embolism in the differential diagnosis, particularly during
procedures that carry a high risk of the complication.
9: Emerg Med Clin North Am
department management of pulmonary embolism.
Department of Emergency Medicine, Beth Israel
Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts,
There are several points that bear repetition.
First, consider the diagnosis of PE in all patients presenting with chest
pain, dyspnea, syncope, oxygen desaturation, or unexplained hypotension.
Evaluate these patients in a rational manner. At any individual hospital,
develop algorithms with consultants so that when one is faced with a
patient with a PE, the flow of both diagnostics and therapeutics flows
smoothly and rapidly. Consider the concept of risk stratification, and
remember that not all patients with PE are created equal. In particular,
be on the same page with all consultants regarding the use of right heart
echocardiography, both for its potential diagnostic capabilities and for
its ability to identify patients who could be at greater risk for bad
10: Emerg Med Clin North Am
diagnostic modalities for pulmonary embolism. Pulmonary angiography using
CT and MR imaging compared with conventional angiography.
Bloomgarden DC, Rosen MP.
Department of Radiology, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
CTPA is a highly sensitive and excellent primary
method for evaluating patients with symptoms of PE. Ongoing studies will
demonstrate the good clinical outcome of patients with negative CTPA
results. The ability to visualize the lung parenchyma in addition to the
pulmonary vasculature, and the smaller number of nondiagnostic scans, make
CT more cost effective than V/Q scans, and CT therefore should be used as
a first-line evaluation. MR imaging is a continually developing modality
with more imaging options that could make it an invaluable or adjunctive
test in the near future.
11: Emerg Med Clin North Am
Kumar AM, Parker JA.
Department of Emergency Medicine, Brigham and
Women's Hospital, Boston, Massachusetts, USA.
V/Q imaging is often very useful in evaluating
patients in whom a PE is suspected. A normal scan result can be used to
exclude embolism and a high likelihood ratio scan can be used to make the
diagnosis of PE. Most patients with PE do not have high likelihood ratio
scans; therefore, it is important to pursue this diagnosis in patients
with intermediate likelihood ratio scans and in the appropriate clinical
setting for patients with the low likelihood ratio scans. In patients with
parenchymal chest x-ray abnormalities who are likely to fall into the
intermediate category, it can be more appropriate to use CT angiography
instead of V/Q scintigraphy. This strategy probably increases the fraction
of scans with high diagnostic utility.
12: Emerg Med Clin North Am
tests for pulmonary embolism.
Weiner SG, Burstein JL.
Department of Emergency Medicine, Beth Israel
Deaconess Medical Center, Boston, Massachusetts, USA.
Many tests have been proposed as useful in the
diagnostic evaluation of suspected PE, but nonspecific tests for PE can
only add to the level of suspicion one has for the diagnosis. As Anderson
indicates, "virtually all clinical and laboratory findings neither
diagnose nor exclude the diagnosis of PE. They merely serve to heighten
suspicion of the diagnosis and prompt the clinician to pursue additional
diagnostic studies." D-dimer measurement is promising as a test to
exclude PE in young healthy out-patients, and further study and
improvements in technology, can clarify the usefulness of the different
methods of performing this assay. For now, diagnostic algorithms for PE
should continue to incorporate multiple tests and decision points, but the
standard remains specialized imaging techniques.
13: Emerg Med Clin North Am
manifestation of pulmonary embolism.
Lee LC, Shah K.
Beth Israel Deaconess Medical Center, Harvard
Medical School, Boston, MA, USA. email@example.com
Results of prospective studies have shown that
physicians' estimate of clinical likelihoods of PE have predictive value.
The ability of clinicians to assess the factors that determine the
probability of disease based on clinical manifestations such as history
and signs and symptoms at presentation, and to make bedside estimates of
that probability, has not been systematically studied. Data suggest that
that this would be a fruitful area of future investigation. Susec et al
noted that there has been a total of three studies (including their own)
which have examined the clinical features such as risk factors, signs, and
symptoms associated with PE in ambulatory outpatients. Hence, the data
collected thus far might not be generalizable to the ED patient
population. As with other illnesses, the ED patients usually present later
and more atypically. The prevalence of PE could be lower among this
population compared with hospitalized patients, causing a lower positive
predictive value, derivable from the clinical features and risk factors at
presentation. Finally, the ED patient population is usually healthier and
younger than the hospitalized patients, and it is well recognized that PE
can be clinically silent in young patients and that 28% have no associated
risk factors. Based on their finding, the authors argue that clinical
pathways to risk stratify patients in an ambulatory setting could be less
useful than anticipated. The validity of these findings needs further
Mayo Clin Proc 2001
of venous thromboembolism in hospitalized patients vs community residents.
Heit JA, Melton LJ 3rd, Lohse CM, Petterson TM,
Silverstein MD, Mohr DN, O'Fallon WM.
Division of Cardiovascular Diseases and Internal
Medicine, Mayo Clinic, Rochester, MN 55905, USA.
OBJECTIVE: To estimate the incidence rates of
deep venous thrombosis (DVT) and pulmonary embolism (PE) in hospitalized
patients and to compare these with incidence rates in community residents.
PATIENTS AND METHODS: We performed a retrospective review of the complete
medical records from a population-based inception cohort of patients who
resided in Olmsted County, Minnesota, and had an incident DVT or PE from
1980 through 1990. RESULTS: From 1980 through 1990, 911 Olmsted County
residents experienced their first lifetime event of definite, probable, or
possible venous thromboembolism. Of these residents, 253 had been
hospitalized for some reason other than a diagnosis of DVT or PE
(in-hospital cases), and 658 were not hospitalized at onset of venous
thromboembolism (community residents). The average annual age- and
sex-adjusted incidence of in-hospital venous thromboembolism was 960.5
(95% confidence interval, 795.1-1125.9) per 10,000 person-years and was
more than 100 times greater than the incidence among community residents
at 7.1 (95% confidence interval, 6.5-7.6) per 10,000 person-years. The
incidence of venous thromboembolism rose markedly with increasing age for
both groups, with PE accounting for most of the age-related increase among
in-hospital cases. Incidence rates in the 2 groups changed little over
time despite a reduction in the average length of hospital stay between
1980 and 1990. CONCLUSIONS: Venous thromboembolism is a major national
health problem, especially among elderly hospitalized patients. This
finding emphasizes the need for accurate identification of hospitalized
patients at risk for venous thromboembolism and a better understanding of
the mechanisms involved so that safe and effective prophylaxis can be
15: Crit Care Med 2001 Nov;29(11):2211-9
during cardiopulmonary resuscitation in fulminant pulmonary embolism: a
MR, Cuadra JA, Aguayo De Hoyos E.
Intensive Care Unit, Critical Care and
Emergencies Department, Hospital de Poniente, El Ejido, Almeria, Spain.
OBJECTIVE: To review current knowledge on
thrombolysis in patients with fulminant pulmonary embolism (FPE) who need
cardiopulmonary resuscitation (CPR). DATA SOURCES: The bibliography for
the study was compiled through a search of different databases between
1966 and 2000. References cited in the articles selected were also
reviewed. STUDY SELECTION: The selection criteria included all reports
published on thrombolysis, pulmonary embolism, and CPR, from case reports
and case series to controlled studies. DATA SYNTHESIS: Very few studies
evaluated thrombolysis in cases of FPE that required CPR and most of these
were clinical case reports and case series with a low level of scientific
evidence. There has been no clinical trial to address this issue.
CONCLUSIONS: FPE can frequently produce cardiac arrest, which has an
extremely high mortality despite application of the usual CPR measures.
The administration of thrombolytic therapy during CPR could help to reduce
the mortality, although it has classically been contraindicated. There are
no published clinical trials or other high-grade studies that evaluated
the efficacy and safety of this approach. From the few existing studies,
it can be inferred that thrombolysis may be efficacious and safe for
patients with FPE who need CPR. However, a clinical trial is required to
provide evidence of value for sound clinical decision-making.
16: Curr Opin Pulm Med
in pulmonary embolism.
Department of Medicine, St. Joseph's Hospital,
McMaster University, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6,
Acute pulmonary embolism has a wide prognostic
spectrum, ranging from sudden death within minutes of a thromboembolic
episode to a benign treatable condition associated with a stable clinical
course and no long-term sequelae. In patients who survive an initial
thromboembolic episode and receive antithrombotic therapy, the clinical
course can be complicated by recurrent nonfatal venous thromboembolism,
fatal pulmonary embolism, the postthrombotic syndrome, and chronic
thromboembolic pulmonary hypertension. Identifying which patients are at
increased risk of experiencing these sequelae is important in decision
making relating to the aggressiveness of initial antithrombotic therapy,
the duration of antithrombotic therapy, and the frequency of clinical
surveillance. In addition, this information may be helpful to clinicians
in discussing disease prognosis with patients. The objectives of this
review are to provide reasonable estimates of the risks of recurrent
nonfatal venous thromboembolism, fatal pulmonary embolism, the
postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension
in patients with treated pulmonary embolism, and to identify risk factors
for these sequelae.
17: Curr Opin Pulm Med
methods for estimating pretest probability in the diagnosis of pulmonary
Ghali WA, Cornuz J, Perrier A.
Department of Medicine, University of Calgary,
3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada.
The clinical assessment of the probability of
pulmonary embolism is a key step in proposed diagnostic strategies for
pulmonary embolism, because the interpretation of noninvasive test results
is conditional on the pretest probability derived from the presence or
absence of clinical factors. The past year has brought important progress
in the general area of clinical prediction of pulmonary embolism with the
publication of two new simple clinical prediction rules. Each of the
prediction rules includes a total of seven clinical variables that, when
combined, allow for the categorization of patients into categories of low,
intermediate, or high pretest probability of pulmonary embolism. Although
these clinical prediction rules are perhaps only slightly better than the
estimates of experienced clinicians, they provide an explicit method for
estimating the probability of PE as an adjunct to diagnostic testing.
Further validation work is now needed to assess how well these new
prediction rules perform in settings other than the derivation sites.
18: BMJ 2001
Sep 15;323(7313):601-2 [Texto
Seasonal variations in hospital admission for
deep vein thrombosis and pulmonary embolism: analysis of discharge data.
Boulay F, Berthier F, Schoukroun G, Raybaut C,
Gendreike Y, Blaive B.
Department of Public Health and Medical
Information, Nice Teaching Hospital, BP 1179, 06003 Nice, Cedex 1, France.
19: Eur Heart J 2000 Aug;21(16):1301-36 [Texto
completo en formato PDF]
Guidelines on diagnosis and management of
acute pulmonary embolism.
Task Force on Pulmonary Embolism, European
Society of Cardiology. Publication Types: Consensus Development Conference
Guideline Practice Guideline Review
20: Ann Intern Med 2000 Feb 1;132(3):227-32
Sensitivity and specificity of helical
computed tomography in the diagnosis of pulmonary embolism: a systematic
Rathbun SW, Raskob GE, Whitsett TL.
Department of Medicine, University of Oklahoma
Health Sciences Center, Oklahoma City 73190, USA.
PURPOSE: To determine the sensitivity and
specificity of helical computed tomography (CT) for the diagnosis of
pulmonary embolism and to determine the safety of withholding
anticoagulant therapy in patients who have clinically suspected pulmonary
embolism and negative results on helical CT. DATA SOURCES: The MEDLINE
database was searched for all reports published from 1986 to October 1999
that evaluated the use of helical CT for the diagnosis of pulmonary
embolism. Bibliographies of the retrieved articles were cross-checked to
identify additional studies. STUDY SELECTION: All prospective
English-language studies were selected. Retrospective studies, review
articles, and case reports were excluded, and 5 of the 20 identified
articles were excluded. The scientific validity of the remaining 15
articles was assessed. DATA EXTRACTION: Two of the authors used a priori,
pre-defined criteria to independently assess each study. A third author
resolved disagreements by adjudication. The pre-defined criteria were
inclusion of a consecutive series of all patients with suspected pulmonary
embolism, inclusion of patients with and those without pulmonary embolism,
a broad spectrum of patient characteristics, performance of helical CT and
pulmonary angiography (or an appropriate reference test) in all patients,
and independent interpretation of the CT scan and pulmonary angiogram (or
reference test). Specific data on sensitivity and specificity and the
associated 95% Cis were recorded when available. DATA SYNTHESIS: No study
met all of the predefined criteria for adequately evaluating sensitivity
and specificity. The reported sensitivity of helical CT ranged from 53% to
100%, and specificity ranged from 81% to 100%. In no prospective study was
anticoagulant therapy withheld without further testing for venous
thromboembolism in consecutive patients with suspected pulmonary embolism.
One prospective study reported the outcome of selected patients with
negative results on helical CT who did not receive anticoagulant therapy.
CONCLUSIONS: Use of helical CT in the diagnosis of pulmonary embolism has
not been adequately evaluated. The safety of withholding anticoagulant
treatment in patients with negative results on helical CT is uncertain.
Definitive large, prospective studies should be done to evaluate the
sensitivity, specificity, and safety of helical CT for diagnosis of
suspected pulmonary embolism.