American Journal of Cardiology
Volume 103, Issue 6 , Pages 881-886 , 15 March 2009

Diagnosis of Pulmonary Embolism in the Coronary Care Unit

  • Paul D. Stein, MD

      Affiliations

    • Department of Research, St. Joseph Mercy Oakland Hospital, Pontiac, Michigan
    • Department of Medicine, Wayne State University, Detroit, Michigan
    • Corresponding Author InformationCorresponding author: Tel: 248-858-6772; fax: 248-858-6974
    • ,
  • H. Dirk Sostman, MD

      Affiliations

    • Office of the Dean, Weill Cornell Medical College and Methodist Hospital, Houston, Texas
    • ,
  • Russell D. Hull, MBBS, MSc

      Affiliations

    • Department of Medicine, University of Calgary, Calgary, Alberta, Canada
    • ,
  • Lawrence R. Goodman, MD

      Affiliations

    • Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
    • ,
  • Kenneth V. Leeper Jr., MD

      Affiliations

    • Department of Medicine, Emory University, Atlanta, Georgia
    • ,
  • Alexander Gottschalk, MD

      Affiliations

    • Department of Radiology, Michigan State University, East Lansing, Michigan
    • ,
  • Victor F. Tapson, MD

      Affiliations

    • Department of Medicine, Duke University, Durham, North Carolina
    • ,
  • Pamela K. Woodard, MD

      Affiliations

    • Department of Radiology, Washington University, St. Louis, Missouri

Received 10 October 2008 ,Revised 9 November 2008 ,Accepted 9 November 2008.

References 

  1. Pulido T, Aranda A, Zevallos MA, Bautista E, Martínez-Guerra ML, Santos LE, et al. Pulmonary embolism as a cause of death in patients with heart failure (An autopsy study). Chest. 2006;129:1282–1287
  2. Darze ES, Latado AL, Guimarães AG, Guedes RA, Santos AB, de Moura SS, et al. Incidence and clinical predictors of pulmonary embolism in severe heart failure patients admitted to a coronary care unit. Chest. 2005;128:2576–2580
  3. Goldhaber SZ. Diagnosis of acute pulmonary embolism: always be vigilant. Am J Med. 2007;120:827–828
  4. Stein PD, Terrin ML, Hales CA, Palevsky HI, Saltzman HA, Thompson BT, et al. Clinical, laboratory, roentgenographic and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest. 1991;100:598–603
  5. Beemath A, Stein PD, Skaf E, Al Sibae MR, Alesh I. Risk of venous thromboembolism in patients hospitalized with heart failure. Am J Cardiol. 2006;98:793–795
  6. Howell MD, Geraci JM, Knowlton AA. Congestive heart failure and outpatient risk of venous thromboembolism: a retrospective, case-control study. J Clin Epidemiol. 2001;54:810–816
  7. Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, et al Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007;120:871–879
  8. Stein PD, Afzal A, Henry JW, Villarreal C. Fever in acute pulmonary embolism. Chest. 2000;117:39–42
  9. Stein PD, Saltzman HA, Weg JG. Clinical characteristics of patients with acute pulmonary embolism. Am J Cardiol. 1991;68:1723–1724
  10. Stein PD, Henry JW. Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes. Chest. 1997;112:974–979
  11. Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, et al Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Am J Med. 2006;119:1048–1055
  12. British Thoracic Society, Standards of Care Committee, Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax. 2003;58:470–484
  13. Remy-Jardin M, Pistolesi M, Goodman LR, Gefter WB, Gottschalk A, Mayo JR, et al. Management of suspected acute pulmonary embolism in the era of CT angiography: a statement of the Fleischner Society. Radiology. 2007;245:315–329
  14. Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, et al Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2008;29:2276–2315
  15. Stein PD, Sostman HD, Bounameaux H, Buller HR, Chenevert TL, Dalen JE, et al Challenges in the diagnosis of acute pulmonary embolism. Am J Med. 2008;121:565–571
  16. PIOPED Investigators. Value of the ventilation-perfusion scan in acute pulmonary embolism: results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). JAMA. 1990;263:2753–2759
  17. Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward (A simple score). Arch Intern Med. 2001;161:92–97
  18. Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135:98–107
  19. Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006;144:165–171
  20. Stein PD, Goldhaber SZ, Henry JW, Miller AC. Arterial blood gas analysis in the assessment of suspected acute pulmonary embolism. Chest. 1996;109:78–81
  21. Stein PD, Goldhaber SZ, Henry JW. Alveolar-arterial oxygen gradient in the assessment of acute pulmonary embolism. Chest. 1995;107:139–143
  22. Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW. The electrocardiogram in acute pulmonary embolism. Prog Cardiovasc Dis. 1975;17:247–257
  23. Lynch RE, Stein PD, Bruce TA. Leftward shift of frontal plane QRS axis as a frequent manifestation of acute pulmonary embolism. Chest. 1972;61:443–446
  24. Stein PD, Willis PW, DeMets DL, Greenspan RH. Plain chest roentgenogram in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Am J Noninvas Cardiol. 1987;1:171–176
  25. Weber DM, Phillips JH. A re-evaluation of electrocardiographic changes accompanying acute pulmonary embolism. Am J Med Sci. 1966;251:381–398
  26. Stein PD, Alshabkhoun S, Hatem C, Pur-Shahriari AA, Haynes FW, Harken DW, et al. Coronary artery blood flow in acute pulmonary embolism. Am J Cardiol. 1968;21:32–37
  27. Stein PD, Alshabkhoun S, Hawkins HF, Hyland JW, Jarrett CE. Right coronary blood flow in acute pulmonary embolism. Am Heart J. 1969;77:356–362
  28. Tapson VF. Diagnosing and managing acute pulmonary embolism: role of cardiac troponins. Am Heart J. 2003;145:751–753
  29. Douketis JD, Crowther MA, Stanton EB, Ginsberg JS. Elevated cardiac troponin levels in patients with submassive pulmonary embolism. Arch Intern Med. 2002;162:79–81
  30. Stein PD. Pulmonary Embolism. In: 2nd ed.. Oxford, United Kingdom: Blackwell Futura; 2007;p. 221;25
  31. Konstantinides S, Geibel A, Olschewski M, Kasper W, Hruska N, Jäckle S, et al. Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism. Circulation. 2002;106:1263–1268
  32. Pruszczyk P, Bochowicz A, Kostrubiec M, Torbicki A, Szulc M, Gurba H, et al. Myoglobin stratifies short-term risk in acute major pulmonary embolism. Clin Chim Acta. 2003;338:53–56
  33. Tulevski II, Hirsch A, Sanson BJ, Romkes H, van der Wall EE, van Veldhuisen DJ, et al. Increased brain natriuretic peptide as a marker for right ventricular dysfunction in acute pulmonary embolism. Thromb Haemost. 2001;86:1193–1196
  34. Kucher N, Printzen G, Doernhoefer T, Windecker S, Meier B, Hess OM. Low pro-brain natriuretic peptide levels predict benign clinical outcome in acute pulmonary embolism. Circulation. 2003;107:1576–1578
  35. Kucher N, Goldhaber SZ. Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Circulation. 2003;108:2191–2194
  36. Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, et al. d-dimer for the exclusion of deep venous thrombosis and acute pulmonary embolism: a systematic review. Ann Intern Med. 2004;140:589–602
  37. Di Nisio M, Squizzato A, Rutjes AW, Büller HR, Zwinderman AH, Bossuyt PM. Diagnostic accuracy of d-dimer test for exclusion of venous thromboembolism: a systematic review. J Thromb Haemost. 2007;5:296–304
  38. Schrecengost JE, LeGallo RD, Boyd JC, Moons KG, Gonias SL, Rose CE, et al. Comparison of diagnostic accuracies in outpatients and hospitalized patients of d-dimer testing for the evaluation of suspected pulmonary embolism. Clin Chem. 2003;49:1483–1490
  39. Shitrit D, Bar-Gil Shitrit A, Rudensky B, Sulkes J, Tzviony D. Determinants of ELISA d-dimer sensitivity for unstable angina pectoris as defined by coronary catheterization. Am J Hematol. 2004;76:121–125
  40. Lippi G, Filippozzi L, Montagnana M, Salvagno GL, Guidi GC. Diagnostic value of d-dimer measurement in patients referred to the emergency department with suspected myocardial ischemia. J Thromb Thrombolysis. 2008;25:247–250
  41. Lew AS, Berberian L, Cercek B, Lee S, Shah PK, Ganz W. Elevated serum d dimer: a degradation product of cross-linked fibrin (XDP) after intravenous streptokinase during acute myocardial infarction. J Am Coll Cardiol. 1986;7:1320–1324
  42. Cugno M, Mari D, Meroni PL, Gronda E, Vicari F, Frigerio M, et al. Haemostatic and inflammatory biomarkers in advanced chronic heart failure: role of oral anticoagulants and successful heart transplantation. Br J Haematol. 2004;126:85–92
  43. Goodman LR, Sostman HD, Stein PD. CT venography: a necessary adjunct to CT pulmonary angiography or a waste of time, money, and radiation?. Radiology. 2009;250
  44. Stein PD, Matta F, Yaekoub AY, Kazerooni EA, Cahill JE, Goodman LR, Sostman HD, Hales CA, Denier JE, Weg JG, et al. CT venous phase venography with 64-slice CT angiography in the diagnosis of acute pulmonary embolism. Clin Appl Thromb. In press.
  45. Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, et al Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354:2317–2327
  46. Turkstra F, Kuijer PM, van Beek EJ, Brandjes DP, ten Cate JW, Buller HR. Diagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism. Ann Intern Med. 1997;126:775–781
  47. Henry JW, Stein PD, Gottschalk A, Relyea B, Leeper KV. Scintigraphic lung scans and clinical assessment in critically ill patients with suspected acute pulmonary embolism. Chest. 1996;109:462–466
  48. Radiation dose to patients from radiopharmaceuticals (addendum 2 to ICRP publication 53). Ann ICRP. 1998;28:1–126
  49. Anderson DR, Kahn SR, Rodger MA, Kovacs MJ, Morris T, Hirsch A, et al Computerized tomographic pulmonary angiography versus ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA. 2007;298:2743–2753
  50. Sostman HD, Stein PD, Gottschalk A, Matta F, Hull R, Goodman L. Sensitivity and specificity of ventilation-perfusion scintigraphy for acute pulmonary embolism in PIOPED II. Radiology. 2008;246:941–946
  51. Forbes KP, Reid JH, Murchison JT. Do preliminary chest x-ray findings define the optimum role of pulmonary scintigraphy in suspected pulmonary embolism?. Clin Radiol. 2001;56:397–400
  52. Gottschalk A, Stein PD, Sostman HD, Matta F, Beemath A. Very low probability interpretation of ventilation-perfusion lung scans in combination with low probability clinical assessment reliably excludes pulmonary embolism: data from PIOPED II. J Nucl Med. 2007;48:1411–1415
  53. Miniati M, Pistolesi M, Marini C, Di Ricco G, Formichi B, Prediletto R, et al. Value of perfusion lung scan in the diagnosis of pulmonary embolism: results of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-PED). Am J Respir Crit Care Med. 1996;154:1387–1393
  54. Cannon CP, Goldhaber SZ. Cardiovascular risk stratification of pulmonary embolism. Am J Cardiol. 1996;78:1149–1151
  55. Stein PD, Beemath A, Matta F, Goodman LR, Weg JG, Hales CA, et al. Enlarged right ventricle without shock in acute pulmonary embolism: prognosis. Am J Med. 2008;121:34–42
  56. Krivec B, Voga G, Zuran I, Skale R, Pareznik R, Podbregar M, et al. Diagnosis and treatment of shock due to massive pulmonary embolism: approach with transesophageal echocardiography and intrapulmonary thrombolysis. Chest. 1997;112:1310–1316
  57. Steiner P, Lund GK, Debatin JF, Steiner D, Nienaber C, Nicolas V, et al. Acute pulmonary embolism: value of transthoracic and transesophageal echocardiography in comparison with helical CT. AJR Am J Roentgenol. 1996;167:931–936
  58. Stein PD, Woodard PK, Hull RD, Kayali F, Weg JG, Olson RE, et al. Gadolinium enhanced magnetic resonance angiography for detection of acute pulmonary embolism: and in depth review. Chest. 2003;124:2324–2328
  59. US Food and Drug Administration. Public health advisory: update on magnetic resonance imaging (MRI) contrast agents containing gadolinium and nephrogenic fibrosing dermopathy. http://www.fda.gov/cder/drug/advisory/gadolinium_agents_20061222.htmAccessed November 4, 2008
  60. Information for healthcare professionals gadolinium-based contrast agents for magnetic resonance imaging (marketed as Magnevist, MultiHance, Omniscan, OptiMARK, ProHance). http://www.fda.gov/cder/drug/InfoSheets/HCP/gcca_200705.htmAccessed November 4, 2008

 Some of the information contained in this report was partially supported by grants HL63899, HL63931, HL063932, HL63940, HL63981, HL67453, HL077151, HL077154, HL077358, and HL077153 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland.

PII: S0002-9149(08)02112-7

doi: 10.1016/j.amjcard.2008.11.040

American Journal of Cardiology
Volume 103, Issue 6 , Pages 881-886 , 15 March 2009

Article Tools