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Pulmonary Embolism: Difference between revisions
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===Electrocardiogram=== | ===Electrocardiogram=== | ||
[[File:Pulmonary embolism ECG.jpg|thumb|Electrocardiogram of a patient with pulmonary embolism showing [[sinus tachycardia]] of approximately 150 beats per minute and [[right bundle branch block]].]] | [[File:Pulmonary embolism ECG.jpg|thumb|Electrocardiogram of a patient with pulmonary embolism showing [[sinus tachycardia]] of approximately 150 beats per minute and [[right bundle branch block]].]] | ||
An [[electrocardiogram]] (ECG) is routinely done on patients with chest pain to quickly diagnose [[myocardial infarction]]s (heart attacks). An ECG may show signs of right heart strain or acute ''[[cor pulmonale]]'' in cases of large PEs - the classic signs are a large S wave in lead I, a large Q wave in lead III and an inverted [[T wave]] in lead III ("S1Q3T3").< | An [[electrocardiogram]] (ECG) is routinely done on patients with chest pain to quickly diagnose [[myocardial infarction]]s (heart attacks). An ECG may show signs of right heart strain or acute ''[[cor pulmonale]]'' in cases of large PEs - the classic signs are a large S wave in lead I, a large Q wave in lead III and an inverted [[T wave]] in lead III ("S1Q3T3"). <cite>McGinn</cite> This is occasionally (up to 20%) present, but may also occur in other acute lung conditions and has therefore limited diagnostic value. The most commonly seen signs in the ECG is [[sinus tachycardia]], right axis deviation and [[right bundle branch block]]. <cite>REFNAME21</cite> Sinus tachycardia was however still only found in 8 - 69% of people with PE. <cite>REFNAME22</cite> | ||
===Echocardiography=== | ===Echocardiography=== | ||
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In most cases, [[anticoagulant]] therapy is the mainstay of treatment. [[Heparin]], [[low molecular weight heparin]]s (such as [[enoxaparin]] and [[dalteparin]]), or [[fondaparinux]] is administered initially, while [[warfarin]], [[acenocoumarol]], or [[phenprocoumon]] therapy is commenced (this may take several days, usually while the patient is in the hospital). [[Low molecular weight heparin]] may reduce bleeding among patients with pulmonary embolism as compared to heparin according to a [[systematic review]] of [[randomized controlled trial]]s by the [[Cochrane Collaboration]]. <cite>REFNAME28</cite> The [[relative risk reduction]] was 40.0%. For patients at similar risk to those in this study (2.0% had bleeding when not treated with low molecular weight heparin), this leads to an [[absolute risk reduction]] of 0.8%. 125.0 patients [[number needed to treat|must be treated for one to benefit]]. | In most cases, [[anticoagulant]] therapy is the mainstay of treatment. [[Heparin]], [[low molecular weight heparin]]s (such as [[enoxaparin]] and [[dalteparin]]), or [[fondaparinux]] is administered initially, while [[warfarin]], [[acenocoumarol]], or [[phenprocoumon]] therapy is commenced (this may take several days, usually while the patient is in the hospital). [[Low molecular weight heparin]] may reduce bleeding among patients with pulmonary embolism as compared to heparin according to a [[systematic review]] of [[randomized controlled trial]]s by the [[Cochrane Collaboration]]. <cite>REFNAME28</cite> The [[relative risk reduction]] was 40.0%. For patients at similar risk to those in this study (2.0% had bleeding when not treated with low molecular weight heparin), this leads to an [[absolute risk reduction]] of 0.8%. 125.0 patients [[number needed to treat|must be treated for one to benefit]]. | ||
It is possible to treat low risk patients (risk class I or class II) as [[Patient#Outpatients_and_inpatients|outpatients]].< | It is possible to treat low risk patients (risk class I or class II) as [[Patient#Outpatients_and_inpatients|outpatients]]. <cite>Aujesky2011</cite> A randomised trial of 344 patients (171 outpatients and 168 inpatients) found that outcomes were equivalent whether patients were treated in hospital or at home (there was one death at 90 days in each group). <cite>Aujesky2011</cite> <cite>Aujesky2007</cite> This confirms the findings of an earlier [[systematic review]] of observational studies. <cite>REFNAME29</cite> | ||
Warfarin therapy often requires frequent dose adjustment and monitoring of the INR. In PE, INRs between 2.0 and 3.0 are generally considered ideal. If another episode of PE occurs under warfarin treatment, the INR window may be increased to e.g. 2.5-3.5 (unless there are contraindications) or anticoagulation may be changed to a different anticoagulant e.g. [[low molecular weight heparin]]. In patients with an underlying malignancy, therapy with a course of [[low molecular weight heparin]] may be favored over warfarin based on the results of the CLOT trial. <cite>REFNAME30</cite> | Warfarin therapy often requires frequent dose adjustment and monitoring of the INR. In PE, INRs between 2.0 and 3.0 are generally considered ideal. If another episode of PE occurs under warfarin treatment, the INR window may be increased to e.g. 2.5-3.5 (unless there are contraindications) or anticoagulation may be changed to a different anticoagulant e.g. [[low molecular weight heparin]]. In patients with an underlying malignancy, therapy with a course of [[low molecular weight heparin]] may be favored over warfarin based on the results of the CLOT trial. <cite>REFNAME30</cite> | ||
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#REFNAME19 pmid=17322258 | #REFNAME19 pmid=17322258 | ||
#REFNAME20 pmid=8372182 | #REFNAME20 pmid=8372182 | ||
#McGinn McGinn S., White PD. Acute cor pulmonale resulting from pulmonary embolism. JAMA 1935:104:1473-80 | |||
#REFNAME21 pmid=11018210 | #REFNAME21 pmid=11018210 | ||
#REFNAME22 isbn=1-4051-4166-2 | #REFNAME22 isbn=1-4051-4166-2 | ||
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#REFNAME27 pmid=18318689 | #REFNAME27 pmid=18318689 | ||
#REFNAME28 pmid=15495007 | #REFNAME28 pmid=15495007 | ||
#Aujesky2011 pmid=21703676 | |||
#Aujesky2007 Drahomir Aujesky, MD. Safety Study of Outpatient Treatment for Pulmonary Embolism (OTPE). NCT00425542 | |||
#REFNAME29 pmid=19407049 | #REFNAME29 pmid=19407049 | ||
#REFNAME30 pmid=12853587 | #REFNAME30 pmid=12853587 | ||