Article Review

Acute Pulmonary Embolism Current concept

Giancarlo Agnelli, M.D., and Cecilia Becattini, M.D., Ph.D.

Supervisor :
Alex Kusanto M.D

Presentant :
Alvin Pradipta
Jennifer Kurniawan
 clinical presentation of acute pulmonary
embolism

 Shock/sustained hypotension to mild dyspnea

 may be  asymptomatic
 Risk factors
 male sex
 advanced age
 cancer
 major surgery
 immobilization because of an acute medical
illness
 trauma
 Diagnosis
 suspected  in all patients :
• new or worsening dyspnea
• chest pain
• sustained hypotension
• without an alternative obvious
 diagnostic workup
 Severity of 
• clinical presentation
• patient’s condition (hemodynamically stable or
unstable)
 hemodynamic stability
• clinical probability assessment,
• d-dimer testing
• multidetector computed tomography (CT)
• ventilation–perfusion scanning
 specificity of >> d-dimer level is reduced in
• patients with cancer
• pregnant women
• hospitalized
• elderly patients
HD stable patients
unnecessary further
Low/intermediate clin prob investigation
Normal d-dimer testing

if anticoagulant treatment is not given

estimated 3-month risk of thromboembolism
 0.14%
 If multidetector CT is
• not available ventilation– perfusion
scanning is an alternative
• renal failure
• allergy to contrast dye

 negative predictive value  97%

 diagnostic  30 to 50% of patients with
suspected pulmonary embolism
 hemodynamically unstable 
• multidetector CT should be performed  97%
sensitivity for detecting emboli in the main pulmonary
arteries

 If not available  echocardiography should be

performed to confirm the presence of right
ventricular dysfunction
 hemodynamically unstable
• Shock , or
• SBP < 90 mmHg
• Drop in pressure of >40 mm Hg
• >15 minutes (in the absence of new onset arrhythmia,
hypovolemia, and sepsis)

high clinical probability

venous ultrasonography should
elevated d-dimer level be considered
negative findings on multidetector CT
 Risk Stratification
 should be done promptly
 Based on clinical features and markers of
myocardial dysfunction or injury
 International Cooperative Pulmonary
Embolism Registry  death rate 

• hemodynamically unstable  58%

• hemodynamically stable  15%
 ECG  Right ventricular dysfunction
• increased mortality
 Treatment
 Acute pulmonary embolism requires initial
shortterm therapy
 LMWH 
• Enoxaparin (at a dose of 1 mg/kgBW , twice daily)
• tinzaparin (175 U/kg once daily)
 Fondaparinux  once daily
• 5 mg, BW< 50 kg
• 7.5 mg 50<BW<100 kg
• 10 mg BW>100 kg
 Intravenous unfractionated heparin
• initial bolus dose (80 IU per kilogram or 5000 IU)
• followed by continuous infusion (usually starting with
18 IU /kg/h)
• Target  TT 1.5 to 2.5x normal value

 LMWH & Fondaparinux  excreted in

kidneys
 Mortality  60% in untreated patients
 Reduced < 30% with prompt treatment

 Major contraindications to thrombolytic

therapy
• intracranial disease
• Uncontrolled hypertension
• recent major surgery or trauma (within the past 3
weeks)
 Long-Term Management
 The risk of recurrent pulmonary embolism

• < 1% per year (receiving anticoagulant therapy)

• 2 to 10% per year (after the discontinuation of such
therapy)
Thank You