J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Review

Volume 1, Number 1, April 2009, pages 1-7

The Risk-based Treatment of Acute Pulmonary Embolism

Figure 1. Pathophysiology of hemodynamic instability due to PE. RV, Right Ventricle; LV, Left Ventricle; BNP, Brain Natriuretic Peptide; NT-proBNP, AminoTerminal-proBrain Natriuretic Peptide.

Figure 2. Summary of PE treatment according to modern guidelines. RHD, right heart dysfunction; BNP, brain natriuretic peptide; IV, intravenous; SC, subcutaneous.

**Table 1.** Clinical classification of PE
ATS, American Thoracic Society; ESC, European Society of Cardiology; BTS, British Thoracic Society; ACEP; American College of Emergency Physicians; ACCP; American College of Chest Physicians; RHD; right heart dysfunction.
ATS 1999, ESC 2000, BTS 2003, ACEP 2003, ACCP 2004, ACCP 2008 MASSIVE (cardiac arrest, shock, hypotension) SUB-MASSIVE (normotensive PE with RHD ) NON MASSIVE (normotensive PE without RHD)
ESC 2008 HIGH RISK (cardiac arrest, shock, hypotension) NON HIGH RISK INTERMEDIATE RISK (normotensive PE with RHD and/or high BNP and/or high troponins) LOW RISK (normotensive PE without RHD and low BNP and low troponins)

Table 1. Clinical classification of PE

ATS, American Thoracic Society; ESC, European Society of Cardiology; BTS, British Thoracic Society; ACEP; American College of Emergency Physicians; ACCP; American College of Chest Physicians; RHD; right heart dysfunction.

ATS 1999, ESC 2000, BTS 2003, ACEP 2003, ACCP 2004, ACCP 2008

MASSIVE (cardiac arrest, shock, hypotension)
SUB-MASSIVE (normotensive PE with RHD )
NON MASSIVE (normotensive PE without RHD)

ESC 2008

HIGH RISK (cardiac arrest, shock, hypotension)
NON HIGH RISK
- INTERMEDIATE RISK (normotensive PE with RHD and/or high BNP and/or high troponins)
- LOW RISK (normotensive PE without RHD and low BNP and low troponins)

**Table 2.** ESC criteria for identifying the prognostic risk of PE
Risk (mortality in acute phase %)	Shock/hypotension	Echocardiographic and biomarkers findings of RHD (↑BNP or NTpro-BNP)	Findings of myocardial injury: ↑ troponin I or T
*generally present but not necessary to define high risk
High (15%)	Present	Present*	Present*
Intermediate (3 - 15%)	Absent Absent Absent	Present Absent Present	present Present Absent
Low (< 3%)	Absent	Absent	Absent

Table 2. ESC criteria for identifying the prognostic risk of PE

Risk
(mortality in acute phase %)

Shock/hypotension

Echocardiographic and biomarkers findings of RHD
(↑BNP or NTpro-BNP)

Findings of myocardial injury: ↑ troponin I or T

*generally present but not necessary to define high risk

High
(15%)

Present

Present*

Intermediate
(3 - 15%)

Absent
Absent
Absent

Present
Absent
Present

present
Present
Absent

Low
(< 3%)

Absent

**Table 3.** Contraindications to thrombolysis in PE
Absolute Haemorragic stroke or stroke of unknown origin at any time Ischemic stroke within six months Central nervous system damage or cancer Recent major trauma/surgery/head injury within three weeks Gastrointestinal bleeding within last months Known bleeding
Relative Age over 85 years Transient ischemic attacks in the previous six months Vitamin K antagonists treatment Traumatic cardio-pulmonary resuscitation Non compressible punctures within 30 days Refractary hypertension (systolic blood pressure > 180 mm Hg) Pregnancy or within one week post-partum Infective endocarditis Advanced liver disease Active peptic ulcer

Table 3. Contraindications to thrombolysis in PE

Absolute

Haemorragic stroke or stroke of unknown origin at any time
Ischemic stroke within six months
Central nervous system damage or cancer
Recent major trauma/surgery/head injury within three weeks
Gastrointestinal bleeding within last months
Known bleeding

Relative

Age over 85 years
Transient ischemic attacks in the previous six months
Vitamin K antagonists treatment
Traumatic cardio-pulmonary resuscitation
Non compressible punctures within 30 days
Refractary hypertension (systolic blood pressure > 180 mm Hg)
Pregnancy or within one week post-partum
Infective endocarditis
Advanced liver disease
Active peptic ulcer