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Acute Pulmonary EmbolismA Review

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Importance  Pulmonary embolism (PE) is characterized by occlusion of blood flow in a pulmonary artery, typically due to a thrombus that travels from a vein in a lower limb. The incidence of PE is approximately 60 to 120 per 100 000 people per year. Approximately 60 000 to 100 000 patients die from PE each year in the US.

Observations  PE should be considered in patients presenting with acute chest pain, shortness of breath, or syncope. The diagnosis is determined by chest imaging. In patients with a systolic blood pressure of at least 90 mm Hg, the following 3 steps can be used to evaluate a patient with possible PE: assessment of the clinical probability of PE, D-dimer testing if indicated, and chest imaging if indicated. The clinical probability of PE can be assessed using a structured score or using clinical gestalt. In patients with a probability of PE that is less than 15%, the presence of 8 clinical characteristics (age <50 years, heart rate <100/min, an oxygen saturation level of > 94%, no recent surgery or trauma, no prior venous thromboembolism event, no hemoptysis, no unilateral leg swelling, and no estrogen use) identifies patients at very low risk of PE in whom no further testing is needed. In patients with low or intermediate clinical probability, a D-dimer level of less than 500 ng/mL is associated with a posttest probability of PE less than 1.85%. In these patients, PE can be excluded without chest imaging. A further refinement of D-dimer threshold is possible in patients aged 50 years and older, and in patients with a low likelihood of PE. Patients with a high probability of PE (ie, >40% probability) should undergo chest imaging, and D-dimer testing is not necessary. In patients with PE and a systolic blood pressure of 90 mm Hg or higher, compared with heparin combined with a vitamin K antagonist such as warfarin followed by warfarin alone, direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, are noninferior for treating PE and have a 0.6% lower rate of bleeding. In patients with PE and systolic blood pressure lower than 90 mm Hg, systemic thrombolysis is recommended and is associated with an 1.6% absolute reduction of mortality (from 3.9% to 2.3%).

Conclusions and Relevance  In the US, PE affects approximately 370 000 patients per year and may cause approximately 60 000 to 100 000 deaths per year. First-line therapy consists of direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, with thrombolysis reserved for patients with systolic blood pressure lower than 90 mm Hg.

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Article Information

Corresponding Author: Yonathan Freund, MD, PhD, Service d’accueil des urgences, 47-83 Bd de l’Hôpital, 75013 Paris, France (yonathan.freund@aphp.fr).

Accepted for Publication: September 1, 2022.

Author Contributions: Dr Freund had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Cohen-Aubart, Bloom.

Drafting of the manuscript: Freund, Cohen-Aubart.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Bloom.

Supervision: Freund, Bloom.

Conflict of Interest Disclosures: None reported.

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Couturaud  F , Sanchez  O , Pernod  G ,  et al; PADIS-PE Investigators.  Six months vs extended oral anticoagulation after a first episode of pulmonary embolism: the PADIS-PE randomized clinical trial.   JAMA. 2015;314(1):31-40. doi:10.1001/jama.2015.7046PubMedGoogle ScholarCrossref
Raskob  G , Ageno  W , Cohen  AT ,  et al.  Extended duration of anticoagulation with edoxaban in patients with venous thromboembolism: a post-hoc analysis of the Hokusai-VTE study.   Lancet Haematol. 2016;3(5):e228-e236. doi:10.1016/S2352-3026(16)00023-5PubMedGoogle ScholarCrossref
Pawar  A , Gagne  JJ , Gopalakrishnan  C ,  et al.  Association of type of oral anticoagulant dispensed with adverse clinical outcomes in patients extending anticoagulation therapy beyond 90 days after hospitalization for venous thromboembolism.   JAMA. 2022;327(11):1051-1060. doi:10.1001/jama.2022.1920PubMedGoogle ScholarCrossref
Agnelli  G , Becattini  C , Meyer  G ,  et al; Caravaggio Investigators.  Apixaban for the treatment of venous thromboembolism associated with cancer.   N Engl J Med. 2020;382(17):1599-1607. doi:10.1056/NEJMoa1915103PubMedGoogle ScholarCrossref
Yoo  HH , Nunes-Nogueira  VS , Fortes Villas Boas  PJ .  Anticoagulant treatment for subsegmental pulmonary embolism.   Cochrane Database Syst Rev. 2020;2(2):CD010222. doi:10.1002/14651858.CD010222.pub4PubMedGoogle ScholarCrossref
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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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