Risk Factors for the Assessment of Patients with Pulmonary Embolism

Authors:
John FanikosFrom the Department of Pharmacy and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts

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and
Samuel Z. GoldhaberFrom the Department of Pharmacy and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts

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Volume/Issue:
Volume 4: Issue 9
Online Publication Date:
Oct 2006
DOI:
https://doi.org/10.6004/jnccn.2006.0072
Full access

Pulmonary embolism (PE) occurs frequently among cancer patients, with a spectrum ranging from small, clinically insignificant thrombi to life-threatening massive PE. It is fatal in as many as 14% of cancer patients, primarily by producing right ventricular heart failure and cardiogenic shock. PE diagnosis is difficult because the signs and symptoms imitate other commonly occurring diseases. Clinicians must be able to integrate a wide array of diagnostic imaging tools and laboratory tests to ensure rapid assessment and diagnosis. Risk stratification with the use of cardiac biomarkers and imaging tests to evaluate right ventricular function will identify treatment options. Hemodynamically stable patients can be treated effectively with anticoagulation alone, whereas those with right ventricular dysfunction require an aggressive strategy with thrombolysis, surgical embolectomy, or a catheter-based intervention. When anti-coagulation is contraindicated, a vena caval filter may be deployed. PE treatment must be customized to the individual and consider the existing thrombus burden, presence of underlying cardiopulmonary disease and right side heart dysfunction, and cancer status of the patient. Clinicians should focus on providing adequate thromboprophylaxis in hospitalized cancer patients to avoid PE treatment.

Correspondence: Samuel Z. Goldhaber, MD, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. E-mail: sgoldhaber@partners.org
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  • 1.

    Trousseau A. Phlegmasia alba dolens. Cliniqu Medicale de L'Hotel-Dieu de Paris 1865;3:654–712.

  • 2.

    Stein PD, Beemath A, Oslon RE. Trends in the incidence of pulmonary embolism and deep vein thrombosis in hospitalized patients. Am J Cardiol 2005;95:1525–1526.

    • Search Google Scholar
    • Export Citation
  • 3.

    Anderson FA, Wheeler HB, Goldberg RJ et al.. A population-based perspective of the hospital incidence and case fatality rates of deep vein thrombosis and pulmonary embolism: the Worcester DVT Study. Arch Int Med 1991;151:933–938.

    • Search Google Scholar
    • Export Citation
  • 4.

    Silverstein MD, Heit JA, Mohr DN et al.. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25 year population based study. Arch Intern Med 1998;15:585–593.

    • Search Google Scholar
    • Export Citation
  • 5.

    Heit JA, Silverstein MD, Mohr DN et al.. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med 2000;160:809–815.

    • Search Google Scholar
    • Export Citation
  • 6.

    Levitan N, Dowlati A, Remick SC et al.. Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. Medicine 1999:78;285–291.

    • Search Google Scholar
    • Export Citation
  • 7.

    Khorana AA, Francis CW, Culakova E et al.. Thromboembolism in hospitalized neutropenic cancer patients. J Clin Oncol 2006;24:484–490.

  • 8.

    Lee AYY, Levine MN. Venous thromboembolism and cancer: risks and outcomes. Circulation 2003;107(suppl 1):I17–I21.

  • 9.

    Shen VS, Pollak EW. Fatal pulmonary embolism in cancer patients: is heparin prophylaxis justified? South Med J 1980;73:841–843.

  • 10.

    Sorensen HT, Melemkjaer L, Olsen JH et al.. Prognosis of cancers associated with venous thromboembolism. N Engl J Med 2000;343:1846–1850.

  • 11.

    Hutten BA, Prins MH, Gent M et al.. Incidence of recurrent thromboembolic events and bleeding complications among patients with venous thromboembolism in relation to both malignancy and achieved International Normalized Ratio: a retrospective analysis. J Clin Oncol 2000;18:3078–3083.

    • Search Google Scholar
    • Export Citation
  • 12.

    Prandoni P, Lensing AWA, Piccioli A et al.. Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and thrombosis. Blood 2002;100:3484–3488.

    • Search Google Scholar
    • Export Citation
  • 13.

    Paraleti G, Legnani C, Lee A et al.. A comparison of the safety and efficacy of oral anticoagulation for the treatment of venous thromboembolic disease in patients with or without malignancy. Thromb Haemost 2000;84:805–810.

    • Search Google Scholar
    • Export Citation
  • 14.

    Bona RD, Sivjee KY, Hickey AD et al.. The efficacy and safety of oral anticoagulation in patients with cancer. Thromb Hemost 1995;74:1055–1058.

  • 15.

    Goldhaber SZ, Elliott CG. Acute pulmonary embolism: part 1: epidemiology, pathophysiology, and diagnosis. Circulation 2003;108:2726–2729.

    • Search Google Scholar
    • Export Citation
  • 16.

    Goldhaber SZ. Pulmonary embolism. N Engl J Med 1998;339:93–104.

  • 17.

    Kucher N, Goldhaber SZ. Management of massive pulmonary embolism. Circulation 2005;112:e28–e32.

  • 18.

    Piazza G, Goldhaber SZ. Acute pulmonary embolism: part I: epidemiology and diagnosis. Circulation 2006;114:28–32.

  • 19.

    Kabrhel C, Camargo CA, Goldhaber SZ. Clinical gestalt and the diagnosis of pulmonary embolism. Chest 2005;127:1627–1630.

  • 20.

    Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999;353:1386–1389.

    • Search Google Scholar
    • Export Citation
  • 21.

    Goldhaber SZ, Elliott CG. Acute pulmonary embolism: part II: risk stratification, treatment, and prevention. Circulation 2003;108:2834–2838.

    • Search Google Scholar
    • Export Citation
  • 22.

    Kucher N, Tapson VF, Goldhaber SZ et al.. Risk factors associated with symptomatic pulmonary embolism in a large cohort of deep vein thrombosis. Thromb Haemost 2005;93:494–498.

    • Search Google Scholar
    • Export Citation
  • 23.

    Elliott CG, Goldhaber SZ, Jensen RL. Delays in diagnosis of deep vein thrombosis and pulmonary embolism. Chest 2005;128:3372–3376.

  • 24.

    Lualdi JC, Goldhaber SZ. Right ventricular dysfunction after acute pulmonary embolism: pathophysiologic factors, detection, and therapeutic options. Am Heart J 1995;130:1276–1282.

    • Search Google Scholar
    • Export Citation
  • 25.

    Schoepf UJ, Goldhaber SZ, Costello P. Spiral computed tomography for acute pulmonary embolism. Circulation 2004;109:2160–2167.

  • 26.

    Quiroz R, Kucher N, Schoepf UJ et al.. Right ventricular enlargement on chest computer tomography. Prognostic role in acute pulmonary embolism. Circulation 2004;109:2401–2404.

    • Search Google Scholar
    • Export Citation
  • 27.

    Schoepf UJ, Kucher N, Kipfmueller F et al.. Right ventricular enlargement on chest computer tomography. A predictor of early death in acute pulmonary embolism. Circulation 2004;110:3276–3280.

    • Search Google Scholar
    • Export Citation
  • 28.

    Dunn KL, Wolf JP, Dorfman DM et al.. Normal D-dimer levels in emergency department patients suspected of acute pulmonary embolism. J Am Coll Cardiol 2002;40:1475–1478.

    • Search Google Scholar
    • Export Citation
  • 29.

    Wells PS, Anderson DR, Ginsberg JS et al.. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the simpliRED D-dimer. Thromb Haemost 2000;83:416–420.

    • Search Google Scholar
    • Export Citation
  • 30.

    Kabrhel C, McAfee AT, Goldhaber SZ. The contribution of the subjective component of the Canadian Pulmonary Embolism Score to the overall score in emergency department patients. Acad Emerg Med 2005;12:915–920.

    • Search Google Scholar
    • Export Citation
  • 31.

    Wells PS, Anderson DR, Rodger M 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.

    • Search Google Scholar
    • Export Citation
  • 32.

    Kearon C, Ginsberg JS, Douketis J et al.. An evaluation of D-dimer in the diagnosis of pulmonary embolism: a randomized trial. Ann Intern Med 2006;144:812–821.

    • Search Google Scholar
    • Export Citation
  • 33.

    Rodger MA, Bredeson CN, Jones G. The bedside investigation of pulmonary embolism diagnosis study. A double-blind randomized controlled trial comparing combinations of 3 bedside tests vs ventilation-perfusion scan for the initial investigation of suspected pulmonary embolism. Arch Intern Med 2006;166:181–187.

    • Search Google Scholar
    • Export Citation
  • 34.

    Kucher N, Goldhaber SZ. Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Circulation 2003;108:2191–2194.

    • Search Google Scholar
    • Export Citation
  • 35.

    Scridon T, Scridon C, Skali H et al.. Prognostic significance of troponin elevation and right ventricular enlargement in acute pulmonary embolism. Am J Cardiol 2005;96:303–305.

    • Search Google Scholar
    • Export Citation
  • 36.

    Giannitsis E, Muller-Bardoff M, Kurowski V et al.. Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism. Circulation 2000;102:211–217.

    • Search Google Scholar
    • Export Citation
  • 37.

    Konstantinides S, Geibel A, Olschewski M et al.. Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism. Circulation 2002;106:1263–1268.

    • Search Google Scholar
    • Export Citation
  • 38.

    Kucher N, Printzen G, Goldhaber SZ. Prognostic role of brain natriuretic peptide in acute pulmonary embolism. Circulation 2003; 107:2545–2547.

    • Search Google Scholar
    • Export Citation
  • 39.

    Binder L, Pieske B, Olschewski et al.. N-terminal pro-brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism. Circulation 2005;112:1573–1579.

    • Search Google Scholar
    • Export Citation
  • 40.

    Goldhaber SZ. Echocardiography in the management of pulmonary embolism. Ann Intern Med 2002;136:691-700.

  • 41.

    Kucher N, Rossi E, DeRosa M, Goldhaber SZ. Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mm Hg or higher. Ann Intern Med 2005; 165:1777–1781.

    • Search Google Scholar
    • Export Citation
  • 42.

    Ribeiro A, Lindmarker P, Juhlin-Dannfelt A. Echocardiography Doppler in pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate. Am Heart J 1997;134:479–487.

    • Search Google Scholar
    • Export Citation
  • 43.

    Merli G, Spiro TE, Olsson CG et al.. Subcutaneous enoxaparin once or twice daily compared with intravenous unfractionated heparin for treatment of venous thromboembolic disease. Ann Intern Med 2001;134:191–202.

    • Search Google Scholar
    • Export Citation
  • 44.

    The Matisse Investigators. Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med 2003;349:1695–1702.

    • Search Google Scholar
    • Export Citation
  • 45.

    Simonneau G, Sors H, Charbonnier B et al.. A comparison of low molecular weight heparin with unfractionated heparin for acute pulmonary embolism. The THESEE Study Group. N Engl Med 1997;337:663–669.

    • Search Google Scholar
    • Export Citation
  • 46.

    Hull RD, Raskob GE, Brant RF et al.. Low-molecular weight heparin vs heparin in the treatment of patients with pulmonary embolism. American-Canadian Thrombosis Study Group. Arch Int Med 2000;160:229–236.

    • Search Google Scholar
    • Export Citation
  • 47.

    Quinlan DJ, McQuillan A, Eikelboom JW. Low-molecular-weight heparin compared with intravenous unfractionated heparin for treatment of pulmonary embolism: a meta-analysis of randomized, controlled trials. Ann Intern Med 2004;140:175–183.

    • Search Google Scholar
    • Export Citation
  • 48.

    Kovacs MJ, Anderson DR, Morrow B et al.. Outpatient treatment of pulmonary embolism with dalteparin. Thromb Haemost 2000;83:209–211.

  • 49.

    Stein PD, Kayali F, Olson RE. Twenty-one-year trends in the use of inferior vena caval filters. Arch Int Med 2004;164:1541–1545.

  • 50.

    The PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism. The PREPIC randomized trial. Circulation 2005;112:416–422.

    • Search Google Scholar
    • Export Citation
  • 51.

    Levin JM, Schiff D, Loeffler JS et al.. Complications of therapy of venous thrombembolic disease in patients with brain tumors. Neurology 1993;43:1111–1114.

    • Search Google Scholar
    • Export Citation
  • 52.

    Schiff D, DeAngelis LM. Therapy of venous thromboembolism in patients with brain metastases. Cancer 1994;73:493–498.

  • 53.

    Buller HR, Agnelli G, Hull RD et al.. Antithrombotic therapy for venous thromboembolic disease. The seventh ACCP Conference on antithrombotic and thrombolytic therapy. Chest 2004;126:401s–428s.

    • Search Google Scholar
    • Export Citation
  • 54.

    Goldhaber SZ, Haire WD, Feldstein ML et al.. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion. Lancet 1993;341:501–511.

    • Search Google Scholar
    • Export Citation
  • 55.

    Wan S, Quinlan DJ, Agnelli G et al.. Thrombolysis compared with heparin for the initial management of pulmonary embolism. A meta-analysis of the randomized controlled trials. Circulation 2004;110:744–749.

    • Search Google Scholar
    • Export Citation
  • 56.

    Konstantinides S, Geibel A, Heusel G et al.. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002;347:1147–1150.

    • Search Google Scholar
    • Export Citation
  • 57.

    Fiumara K, Kucher N, Fanikos J et al.. Predictors of major hemorrhage following thrombolysis for acute pulmonary embolism. Am J Cardiol 2006;97:127–129.

    • Search Google Scholar
    • Export Citation
  • 58.

    Aklog L, Williams CS, Byrne JG et al.. Acute pulmonary embolectomy. A contemporary approach. Circulation 2002;105:1416–1419.

  • 59.

    Kucher N, Koo S, Quiroz R et al.. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med 2005;352:969–977.

  • 60.

    Harrington KJ, Bateman AR, Syrigos KN et al.. Cancer-related thromboembolic disease in patients with solid tumours: a retrospective analysis. Oncology 1997;8:669–673.

    • Search Google Scholar
    • Export Citation
  • 61.

    Elting LS, Escalante CP, Cooksley C et al.. Outcomes and cost of deep vein thrombosis among patients with cancer. Arch Int Med 2004;164:1653–1661.

    • Search Google Scholar
    • Export Citation
Copyright:
Copyright © 2006 by the National Comprehensive Cancer Network
Page Numbers:
10
Article Category:
Research Article
Received:
15 Jul 2006
Accepted:
31 Jul 2006
Print Publication Date:
01 Oct 2006
Online Publication Date:
Oct 2006
Keywords:
Pulmonary embolism; thrombolysis; pulmonary embolectomy; anticoagulation; risk stratification
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