Explainers

Pulmonary Embolism – DVT to PE


Throughout history, pulmonary embolism (PE) has almost always been diagnosed on the autopsy table. In other words, it was considered a ‘terminal event.’ 1

Today, PE is seen as a modern-day medical dichotomy: we understand its minutia and yet, somehow, still fail to diagnose or tackle it appropriately.

Appropriately treated, pulmonary embolism need not live up to its historical reputation as a life-ender.

Pulmonary Embolism Facts and Figures

Australia experiences approximately 17,000 new cases of venous thromboembolism annually with pulmonary embolism accounting for 4 out of 10 cases.

Although PE is a significant factor in mortality and morbidity, the latest Australian and UK statistics on deaths due to pulmonary embolism are much lower than their counterparts in the U.S. 2

In 2015, PE accounted for only 0.2% and 0.4% of all deaths in Australia and the UK, respectively. 3,4 This is a far smaller mortality percentage than seen during the same time period in the U.S. 5

What is a Pulmonary Embolism?

Pulmonary embolism is a natural consequence of a cascade of unfortunate events which begin with a thrombus formation, typically in a deep vein of the legs, thighs, or pelvis (Fig. 1).

Deep vein thrombosis in leg veins. Pulmonary Embolism (PE) - DVT to PE, Symptoms, Treatment & Causes

Figure 1: Deep vein thrombosis in leg veins.

With venous thromboembolism events, where there is smoke, there is usually fire. Three risk factors, collectively described as the Virchow triad (Fig. 2), are the ‘smoke’ that occurs prior to a PE diagnostic fire.

Virchow’s Triad

The first leg of the Virchow triad is venous stasis, the second, trauma and the third, hypercoagulability. 6

 Virchow's Triad Pulmonary Embolism (PE) - DVT to PE, Symptoms, Treatment & Causes

Figure 2: Virchow’s Triad, ((CC) Rudolf.hellmuth 2012).

The presence of these risk factors places patients at a significantly elevated risk of the venous event turning into a much bigger pulmonary problem.

In fact, over 50% of patients with a deep vein thrombosis will eventually end up with a diagnosis of pulmonary embolism. 7

Types of Pulmonary Embolism Presentations

Not all pulmonary emboli present the same.

It is not enough for clinicians to eyeball a patient’s clinical presentation to determine the need for medical imaging to rule out PE.

Instead, clinicians should use several valid and reliable checklists comprised of clinician characteristics, like this one by Kline to rule out the likelihood of a pulmonary embolism (PE). 8

A patient who presents with NONE of the following characteristics has a pretest probability of having a PE of less than 1%.

  • Initial heart rate < 100 beats/min
  • Initial oxygen saturation >94% on room air
  • No unilateral leg swelling
  • No hemoptysis
  • No surgery or trauma within 4 weeks
  • No history of venous thromboembolism
  • No estrogen use

If the patient has at least one of the above characteristics, then a PE cannot be ruled unlikely without further assessment.

Pulmonary Embolism Causes

Deep vein thromboses (DVT) can be caused by anything which prevents normal circulation in the legs, including bed rest or other limited movement, injury, bracing, surgery, or even certain types of medications (see risk factors for more info).

DVTs are largely preventable, which means that pulmonary emboli are largely preventable.

Patients who maintain healthy weights, exercise (or at least do not maintain a sedentary lifestyle) and who follow directions related to post-surgery or bedrest are far less likely to develop a DVT.

The most prominent signs of a DVT are: redness or discoloration, swelling, and pain, especially a cramping sensation in the calf (Fig. 3).

A Homans’ sign is no longer considered a sensitive or specific test for DVT; some believe it elevates the risk present for migration.

 A deep vein thrombosis on the right leg Pulmonary Embolism (PE) - DVT to PE, Symptoms, Treatment & Causes

Figure 3: A deep vein thrombosis on the right leg. Note the swelling and redness, ((CC) James Heilman, MD n.d.).

Pulmonary Embolism Symptoms

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Pulmonary embolism typically begins with migration of a thrombus formation (Fig. 4), usually from the deep veins of the leg to the small blood vessels of the lungs. The clot lodges in these smaller pathways and blocks blood flow, potentially leading to tissue death.

migrations of a thrombis into a Pulmonary Embolism (PE) - DVT to PE, Symptoms, Treatment & Causes

Figure 4: the migrations of a thrombis into a pulmonary embolism (PE).

It is important to know that patients can suffer a PE without any prior symptoms of a DVT.

Signs and symptoms of PE can include: 9

  • Laboured breathing
  • Elevated heart rate
  • Arrhythmias
  • Pain or discomfort in the chest
  • Greater chest pain with coughing or deep breathing
  • Coughing up blood
  • Hypotension
  • Lightheadedness
  • Loss of consciousness

Pulmonary Embolism Risk Factors

Risk factors for deep vein thrombosis (and thus for PE) include many events which tend to lead to injuries to the venous structures of the leg, thigh, hip or pelvis.

Fractures, surgery, and significant muscle tears are all conditions which create the potential for DVT formation.

Individuals with slow blood flow have an elevated risk; this flow problem can be due to prolonged sitting like seen in long car rides or aeroplane flights, bed rest, or paralysis.

Pregnancy, hormone replacement therapy and birth control pills are also major culprits because of their common theme: an increase in estrogen delivered to the body.

Catheters located in a central vein must be closely monitored.

Even certain medical conditions such as cardiopulmonary disease, inflammatory bowel conditions, and obesity can increase the risk.

Certainly, a family history of DVT or PE or any type of genetic clotting disorder will also elevate the odds and these odds just get worse in the geriatric population.

Pulmonary Embolism Diagnosis and Testing

Over time, clinicians have developed working models to determine the probability of a PE diagnosis. There are many available, but the Wells model is easy to use and well established.

Wells’ Score for Clinical Prediction 10

Wells’ Clinical Prediction Rule for Pulmonary Embolism

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Active cancer (patient receiving treatment for cancer within 6 months or currently receiving palliative treatment) 1
Hemoptysis 1
History of deep venous thrombosis or pulmonary embolism 1.5
Surgery or bedridden for 3 days or more during the past 4 weeks 1.5
Heart rate > 100 beats/min 1.5
Pulmonary embolism judged to be the most likely diagnosis 3
Clinical signs and symptoms compatible with deep venous thrombosis 3
  • A score of <2 indicates a low probability of pulmonary embolism.
  • A score of 2–6 indicates an intermediate probability of PE.
  • A score of more than 6 indicates a high probability of pulmonary embolism.

Individuals who score a high probability should skip the D dimer assay and go immediately to imaging (CT angiography), which will confirm or refute the presence of a PE.

Individuals with a moderate score should be tested with a high sensitivity D dimer assay. If a high sensitivity D dimer assay is not available, the patient should be imaged immediately with a CT angiography.

A computed tomographic pulmonary angiography (CTPA) is the standard diagnostic imaging tool used to determine the presence of a PE (Fig. 5). This test allows clinicians to visualise the small vessels of the lungs through use of a contrast dye injected into a vein.

Computer Tomographic Pulmonary Angiography (CTPA) Pulmonary Embolism (PE) - DVT to PE, Symptoms, Treatment & Causes

Figure 5: Computer Tomographic Pulmonary Angiography (CTPA), ((CC) James Heilman, MD 2005).

Other tests, such as ventilation-perfusion scans (Fig. 6) and pulmonary angiography, can also be used to diagnose PE.

Magnetic resonance imaging (MRI) can also be useful, but it is typically reserved for special populations where the use of radio waves is preferable to the use of X-rays or where contrast dyes are not tolerated.

Ventilation perfusion scan Pulmonary Embolism (PE) - DVT to PE, Symptoms, Treatment & Causes

Figure 6: Ventilation perfusion scan. A: ventilation, B: perfusion, ((CC) Westage, EJ & Fitzgerald GA 2005).

Pulmonary Embolism Treatment

What is the best course of action for the management of a pulmonary embolism?

The best course of action is always a good defensive strategy.

Compression stockings and vertical immersion in water (a swimming pool) are both great strategies designed to prevent DVTs and PEs (Fig. 7).

compression therapy. Pulmonary Embolism (PE) - DVT to PE, Symptoms, Treatment & Causes

Figure 7: compression therapy.

Medications

Medication may be used for both prevention and treatment of DVTs and PEs.

If properly prescribed, medicines such as anticoagulants and thrombolytics can nip the problem in the bud.

Anticoagulants are often referred to as ‘blood thinners’, but this is not actually what they do. They reduce the ability of blood to clot, allowing the body time to reduce the size of the clot by reabsorption. They also make it less likely that the blood will clot again in the near future.

All anticoagulants increase the likelihood of bruising and bleeding and this means that patients are required to remain under monitoring to determine that they have not over (or under) medicated.

Anticoagulants can be injected (e.g. Heparin or Fondaparinux) or swallowed (Warfarin, Rabigatran, Apixaban, and others).

Thrombolytics work differently than anticoagulants. Their street name (‘clot busters’) is accurate; these medications work to dissolve clots.

Thrombolytics are more aggressive than anticoagulants, with a greater likelihood of uncontrolled bleeding, so they are reserved for more severe situations. 10

Two other management strategies are available if these do not do the job. A filter can be placed in the inferior vena cava in an effort to prevent any clots from migrating from the legs into the lungs (Fig. 8).

This is a prevention strategy and will do nothing after the fact. In contrast, a thrombectomy or embolectomy is a rare surgical procedure which is used to remove a clot in the legs or lungs, respectively. 10

inferior vena cava filterPulmonary Embolism (PE) - DVT to PE, Symptoms, Treatment & Causes

Figure 8: Picture of a used inferior vena cava filter, showing the hook at the top for remove via the jugular vein, the umbrella structure and the leg spikes to fix in place, ((CC) BozMo at English Wikipedia, 2007).

Pulmonary Embolism Prevention

Pulmonary embolism (PE), although serious, can be prevented when correct measures are taken.

The first step to prevent PE is becoming aware of the risk. If at an increased risk, a doctor can recommend medications or graduated compression stockings to help prevent PE from occurring.

Increased risk of PE can also occur when sitting for extended periods of time. This can be mitigated by getting up to walk, wearing loose-fitting clothes while travelling, and exercising the legs while seated.

Stretching leg muscles by lifting your heels off the ground and setting them down again (Fig. 9) is a good way to do this. Finally, maintaining a healthy weight and active lifestyle is key to reducing risk of PE. 11

Exercise for Pulmonary Embolism (PE) - DVT to PE, Symptoms, Treatment & Causes

Figure 9: lifting the heels off the ground to encourage blood circulation in the leg.

Complications of Pulmonary Embolism

As many as half of post-pulmonary embolism (PE) patients may suffer from complications. 12

Common complications can include decreased quality of life, functional limitations, incomplete thrombus resolution, and abnormal pulmonary artery pressure and right ventricular function, among others.

One of the most severe complications, chronic thromboembolic pulmonary hypertension (CTEPH), is associated with a high risk of death. It occurs in just under 0.1% of post-PE patients, but may be underdiagnosed due to the way it presents clinically in a way similar to PE. 13

Identifying and correctly diagnosing CTEPH and other PE-related complications should be a primary concern of post-PE follow-up. 14

Conclusion

Pulmonary embolism is a potentially preventable condition. It is also potentially life-ending.

As already discussed, the best clinical outcome comes when the embolism never makes it to the lungs. And the best way to prevent the embolism from migrating to the lungs is to prevent it from forming in the lower extremities to begin with.

Clinician management of PE has changed over the years, with many excellent tools available to clinicians to allow them to bypass unnecessary tests and delay times. And with pulmonary embolism, time management is the most important treatment tool of them all.

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References

  1. Doherty, S 2017, ‘Pulmonary embolism: An update’, Australian Family Physician (Chest Pain), vol. 46, no. 11, pp. 816-20, viewed 12 April 2018, https://www.racgp.org.au/afp/2017/november/pulmonary-embolism/
  2. Skinner, S 2013, ‘Pulmonary embolism: assessment and imaging’, Australian Family Physician (General Practice Psychiatry), vol. 42, no. 9, pp. 628-32, viewed 12 April 2018, https://www.racgp.org.au/afp/2013/september/pulmonary-embolism/
  3. Australian Bureau of Statistics 2016, Causes of death, Australia, 2015, cat. no. 3303.0, ABS, Canberra, viewed 12 April 2018, http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3303.02015?OpenDocument
  4. British Lung Foundation 2018, Pulmonary embolism statistics, BLF, London, viewed 12 April 2018, https://statistics.blf.org.uk/pulmonary-embolism
  5. Centers for Disease Control and Prevention 2015, Venous thromboembolism (blood clots), CDC, Atlanta, viewed 12 April 2018, https://www.cdc.gov/ncbddd/dvt/data.html
  6. Cervantes J & Rojas G 2005, ‘Virchow’s legacy: deep vein thrombosis and pulmonary embolism.’, World Journal of Surgery, vol. 29, Sup. 1, S30-34, viewed 12 April 2018, https://www.ncbi.nlm.nih.gov/pubmed/15818472
  7. Merli, G, Eraso, LH, Galanis, T & Ouma, G 2017, Pulmonary Embolism, BMJ Best PRactice, viewed 12 April 2018, http://bestpractice.bmj.com/topics/en-us/116#referencePop1
  8. Kline, JA, Courtney, DM, Kabrhel, C, Moore, CL, Smithline, HA, Plewa, MC, Richan, PB, O’Neil, BJ & Nordenholz, K 2008, ‘Prospective multicenter evaluation of the pulmonary embolism rule‐out criteria’, Journal of Thrombosis and Haemostasis, vol. 6, no. 5, pp. 772-80, viewed 12 April 2018, https://www.ncbi.nlm.nih.gov/pubmed/18318689
  9. Centers for Disease Control and Prevention 2017, Venous Thromboembolism (Blood Clots),  CDC, Atlanta, viewed 12 April 2018, https://www.cdc.gov/ncbddd/dvt/facts.html
  10. Streiff, MB, Agnelli, G, Connors, JM, Crowther, M, Eichinger, S, Lopes, R, McBane, RD, Moll, S & Ansell, J 2016, ‘Guidance for the treatment of deep vein thrombosis and pulmonary embolism’, Journal of thrombosis and thrombolysis, vol. 41, no. 1, pp. 32-67, viewed 12 April 2018, https://link.springer.com/article/10.1007/s11239-015-1317-0
  11. Konstantinides, SV, Barco, S, Lankeit, M & Meyer, G 2016, ‘Management of pulmonary embolism: an update’, Journal of the American College of Cardiology, vol. 67, no. 8, pp. 976-90. viewed 12 April 2018, https://www.ncbi.nlm.nih.gov/pubmed/26916489
  12. Klok, FA, Van der Hulle, T, Den Exter, PL, Lankeit, M, Huisman, MV & Konstantinides, S 2014, ‘The post-PE syndrome: a new concept for chronic complications of pulmonary embolism’, Blood reviews, vol. 28, no. 6, pp. 221-6, viewed 12 April 2018, https://www.ncbi.nlm.nih.gov/pubmed/25168205
  13. Guérin, L, Couturaud, F, Parent, F, Revel, MP, Gillaizeau, F, Planquette, B & Sanchez, O 2014, ‘Prevalence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism’, Thrombosis and haemostasis, vol. 112, no. 3, pp. 598-605, viewed 12 April 2018, https://www.ncbi.nlm.nih.gov/pubmed/24898545
  14. D’Agostino, C, Zonzin, P, Enea, I, Gulizia, MM, Ageno, W, Agostoni, P, Azzarito, M, Becattini, C, Bongarzoni, A, Bux, F, Casazza, F, Corrieri, N, D’Alto, M, D’Amato, N, D’Armini, AM, De Natale, MG, Di Minno, G, Favretto, G, Filippi, L, Grazioli, V, Palareti, G, Pesavento, R, Roncon, L, Scelsi, L & Tufano, A 2017, ‘ANMCO Position Paper: long-term follow-up of patients with pulmonary thromboembolism’, European Heart Journal Supplements: Journal of the European Society of Cardiology, vol. 19, Supp. D, D309-D332, viewed 12 April 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5520763/

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