Pulmonary Embolism

Paul D. Stein MD,Professor of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA. Dr. Stein's major research in recent years has been in the field of venous thromboembolism. Dr. Stein initiated the PIOPED II and PIOPED III national collaborative studies and was national principal investigator and chairperson of the steering committees. He has written over 240 articles on venous thromboembolism from among over 560 peer reviewed articles. Dr Stein is a past president of the Laennec Society and of the American College of Chest Physicians. He is Fellow of the American College of Physicians and the American College of Cardiology and a Master Fellow of the American College of Chest Physicians. He is also a Fellow of the American Society of Mechanical Engineers. Fellowship is reserved for those who have made a significant contribution to the field of mechanical engineering. He received the Lifetime Achievement Award from the American Heart Association Midwest Affiliate, the Laureate Award of the American College of Physicians, Michigan Chapter, the Daniel Drake Award from the University of Cincinnati College of Medicine, and the Research Excellence Award from the Michigan State University College of Osteopathic Medicine.  Dr. Stein also wrote a book, A Physical and Physiological Basis for the Interpretation of Cardiac Auscultation:  Evaluations Based Primarily on Second Sound and Ejection Murmurs.

Prologue xi

Preface to the Third Edition xiii

About the companion website xv

Introduction 1

Part I Prevalence, risks, and prognosis of pulmonary embolism and deep venous thrombosis

1 Pulmonary embolism and deep venous thrombosis at autopsy 5

2 Incidence of pulmonary embolism and deep venous thrombosis in hospitalized patients and in emergency departments 18

3 Case fatality rate and population mortality rate from pulmonary embolism and deep venous thrombosis 24

4 Prognosis in acute pulmonary embolism based on right ventricular enlargement and biochemical markers in stable patients 31

5 Prognosis in acute pulmonary embolism based on scoring systems 43

6 Pulmonary embolism following deep venous thrombosis and outcome with untreated pulmonary embolism 49

7 Resolution of pulmonary embolism 54

8 Upper extremity deep venous thrombosis 61

9 Thromboembolic disease involving the superior vena cava and brachiocephalic veins 66

10 Venous thromboembolic disease in the four seasons 69

11 Regional differences in the United States of rates of diagnosis of pulmonary embolism and deep venous thrombosis and mortality from pulmonary embolism 73

12 Venous thromboembolism according to age and in the elderly 78

13 Pulmonary thromboembolism in infants and children 95

14 Venous thromboembolism in men and women 99

15 Pulmonary embolism and deep venous thrombosis in blacks and whites 103

16 Pulmonary thromboembolism in Asians/Pacific Islanders 108

17 Pulmonary thromboembolism in American Indians and Alaskan Natives 116

18 Venous thromboembolism in patients with cancer 118

19 Venous thromboembolism in patients with heart failure 128

20 Obesity as a risk factor in venous thromboembolism 133

21 Hypertension, smoking, and cholesterol 139

22 Overlap of venous and arterial thrombosis risk factors 141

23 Venous thromboembolism in patients with ischemic and hemorrhagic stroke 143

24 Paradoxical embolism 146

25 Pulmonary embolism and deep venous thrombosis in hospitalized adults with chronic obstructive pulmonary disease 149

26 Pulmonary embolism and deep venous thrombosis in hospitalized patients with asthma 156

27 Deep venous thrombosis and pulmonary embolism in hospitalized patients with sickle cell disease 158

28 Diabetes mellitus and risk of venous thromboembolism 162

29 Risk of venous thromboembolism with rheumatoid arthritis 164

30 Venous thromboembolism with inflammatory bowel disease 166

31 Venous thromboembolism with chronic liver disease 168

32 Nephrotic syndrome 171

33 Human immunodeficiency virus infection 173

34 Venous thromboembolism in pregnancy 176

35 Amniotic fluid embolism 182

36 Air travel as a risk for pulmonary embolism and deep venous thrombosis 184

37 Estrogen-containing oral contraceptives and venous thromboembolism 187

38 Estrogen and testosterone in men 192

39 Tamoxifen 194

40 Venous thromboembolism following bariatric surgery 198

41 Hypercoagulable syndrome 204

Part II Diagnosis of deep venous thrombosis

42 Deep venous thrombosis of the lower extremities: clinical evaluation 215

43 Clinical scoring system for assessment of deep venous thrombosis 220

44 Clinical probability score plus single negative ultrasound for exclusion of deep venous thrombosis 223

45 D-dimer for the exclusion of acute deep venous thrombosis 225

46 D-dimer combined with clinical probability assessment for exclusion of acute deep venous thrombosis 234

47 D-dimer and single negative compression ultrasound for exclusion of deep venous thrombosis 236

48 Contrast venography 237

49 Compression ultrasound for the diagnosis of deep venous thrombosis 240

50 Impedance plethysmography and fibrinogen uptake tests for diagnosis of deep venous thrombosis 247

51 Ascending CT venography and venous phase CT venography for diagnosis of deep venous thrombosis 250

52 Magnetic resonance venography for diagnosis of deep venous thrombosis 255

53 P-selectin and microparticles to predict deep venous thrombosis 260

Part III Diagnosis of acute pulmonary embolism

54 Clinical characteristics of patients with no prior cardiopulmonary disease 265

55 Relation of right-sided pressures to clinical characteristics of patients with no prior cardiopulmonary disease 272

56 The history and physical examination in all patients irrespective of prior cardiopulmonary disease 275

57 Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes 280

58 Clinical assessment in the critically ill 286

59 The electrocardiogram 289

60 The plain chest radiograph 303

61 Arterial blood gases and the alveolar–arterial oxygen difference in acute pulmonary embolism 308

62 Fever in acute pulmonary embolism 316

63 Leukocytosis in acute pulmonary embolism 319

64 Alveolar dead-space in the diagnosis of pulmonary embolism 321

65 Empirical assessment and clinical models for diagnosis of acute pulmonary embolism 324

66 Prognostic models for pulmonary embolism 329

67 D-dimer for the exclusion of acute pulmonary embolism 335

68 D-dimer combined with clinical probability for exclusion of acute pulmonary embolism 346

69 D-dimer in combination with amino-terminal pro-B-type natriuretic peptide for exclusion of acute pulmonary embolism 349

70 Tissue plasminogen activator, plasminogen activator inhibitor-1, and thrombin – antithrombin III complexes in the exclusion of acute pulmonary embolism 350

71 Echocardiogram in the diagnosis of acute pulmonary embolism 352

72 Trends in the use of diagnostic imaging in patients hospitalized with acute pulmonary embolism 356

73 Techniques of perfusion and ventilation imaging 358

74 Ventilation – perfusion lung scan criteria for interpretation prior to the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) 363

75 Observations from PIOPED: ventilation – perfusion lung scans alone and in combination with clinical assessment 367

76 Ventilation – perfusion lung scans according to complexity of lung disease 374

77 Perfusion lung scans alone in acute pulmonary embolism 376

78 Probability interpretation of ventilation – perfusion lung scans in relation to the largest pulmonary arterial branches in which pulmonary embolism is observed 379

79 Revised criteria for evaluation of lung scans recommended by nuclear physicians in PIOPED 381

80 Criteria for very-low-probability interpretation of ventilation – perfusion lung scans 385

81 Probability assessment based on the number of mismatched segmental equivalent perfusion defects 391

82 Probability assessment based on the number of mismatched vascular defects and stratification according to prior cardiopulmonary disease 395

83 The addition of clinical assessment to stratification according to prior cardiopulmonary disease further optimizes the interpretation of ventilation – perfusion lung scans 401

84 Pulmonary scintigraphy scans since PIOPED 407

85 Single photon emission computed tomographic (SPECT) lung scans 412

86 SPECT with radiolabeled markers 426

87 Standard and augmented techniques in pulmonary angiography 427

88 Subsegmental pulmonary embolism 435

89 Quantification of pulmonary embolism by conventional and CT angiography 440

90 Complications of pulmonary angiography 442

91 Contrast-enhanced spiral CT for the diagnosis of acute pulmonary embolism before the Prospective Investigation of Pulmonary Embolism Diagnosis II 446

92 Methods of PIOPED II 458

93 Multidetector spiral CT of the chest for acute pulmonary embolism: results of the PIOPED II trial 467

94 Multidetector CT pulmonary angiography since PIOPED II 473

95 Outcome studies of pulmonary embolism versus accuracy 478

96 Contrast-induced nephropathy 480

97 Radiation exposure and risk 483

98 Magnetic resonance angiography for the diagnosis of acute pulmonary embolism 490

99 Serial noninvasive leg tests in patients with suspected pulmonary embolism 499

100 Diagnosis of pulmonary embolism in the coronary care unit 501

101 Silent pulmonary embolism with deep venous thrombosis 506

102 Fat embolism syndrome 511

103 Diagnostic approach to acute pulmonary embolism 516

Part IV Prevention and treatment of deep venous thrombosis and pulmonary embolism

104 Warfarin and other vitamin K antagonists 523

105 Unfractionated heparin, low-molecular-weight heparin, heparinoid, and pentasaccharide 531

106 Parenteral inhibitors of factors Va, VIIIa, tissue factor, and thrombin 540

107 Novel oral anticoagulants 545

108 Aspirin for venous thromboembolism 552

109 Immediate therapeutic levels of heparin in relation to timing of recurrent events 555

110 Intermittent pneumatic compression 558

111 Graduated compression stockings 561

112 Ankle exercise and venous blood velocity 565

113 Thrombolytic therapy for deep venous thrombosis 567

114 Mechanical and ultrasonic enhancement of catheter-directed thrombolytic therapy for deep venous thrombosis 572

115 Thrombolytic therapy for treatment of acute pulmonary embolism 574

116 Catheter-tip embolectomy in the management of acute massive pulmonary embolism 589

117 Vena cava filters 597

118 Withholding treatment of patients with acute pulmonary embolism who have a high risk of bleeding provided and negative serial noninvasive leg tests 615

119 Home treatment of deep venous thrombosis 617

120 Home treatment of acute pulmonary embolism 622

121 Pulmonary embolectomy 626

122 Chronic thromboembolic pulmonary hypertension and pulmonary thromboendarterectomy 634

123 Prevention and treatment of deep venous thrombosis and acute pulmonary embolism: American College of Chest Physicians Guidelines 639

Index 647