Abstract
Pulmonary embolism is a common geriatric medical condition that accounts for significant morbidity and mortality. It is responsible for greater than 200,000 deaths annually and 10% of hospital deaths [1–3]. The incidence of venous thromboembolic disease (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), rises sharply after the age of 60 and reaches 1% per year in the very old. However, while most major studies looking at diagnosis and treatment concentrate on middle-aged subjects [4], almost 70% of all VTE are diagnosed in patients over the age of 60 [1]. This chapter focuses on the pathophysiology of thromboembolic disease in the elderly and explores risk factors, presentation, diagnosis, prevention, and treatment as it pertains to the geriatric population. Complications of treatment are also considered.
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References
Anderson Jr 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 Intern Med. 1991;151(5):933–8.
Brotman DJ, Jaffer AK. Prevention of venous thromboembolism in the geriatric patient. Cardiol Clin. 2008;26(2):221–34. vi.
Tincani E, Crowther MA, Turrini F, Prisco D. Prevention and treatment of venous thromboembolism in the elderly patient. Clin Interv Aging. 2007;2(2):237–46.
Naess IA, Christiansen SC, Romundstad P, Cannegieter SC, Rosendaal FR, Hammerstrom J. Incidence and mortality of venous thrombosis: a population-based study. J Thromb Haemost. 2007;5(4):692–9.
Monreal M, Munoz FJ, Rosa V, et al. Upper extremity DVT in oncological patients: analysis of risk factors. Data from the RIETE registry. Exp Oncol. 2006;28(3):245–7.
Elliott CG. Pulmonary physiology during pulmonary embolism. Chest. 1992;101(4 Suppl): 163S–71.
Goldhaber SZ. Pulmonary embolism. Lancet. 2004;363(9417):1295–305.
Silverstein MD, Heit JA, Mohr DN, Petterson TM, O’Fallon WM, Melton 3rd LJ. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998;158(6):585–93.
Tsai AW, Cushman M, Rosamond WD, Heckbert SR, Polak JF, Folsom AR. Cardiovascular risk factors and venous thromboembolism incidence: the longitudinal investigation of thromboembolism etiology. Arch Intern Med. 2002;162(10):1182–9.
Stein PD, Matta F, Musani MH, Diaczok B. Silent pulmonary embolism in patients with deep venous thrombosis: a systematic review. Am J Med. 2010;123(5):426–31.
Sorensen HT. Venous thromboembolism and the concepts of the incidence and mortality. J Thromb Haemost. 2007;5(4):690–1.
Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353(9162): 1386–9.
Goldhaber SZ, Elliott CG. Acute pulmonary embolism: part I: epidemiology, pathophysiology, and diagnosis. Circulation. 2003;108(22):2726–9.
Siddique RM, Siddique MI, Connors Jr AF, Rimm AA. Thirty-day case-fatality rates for pulmonary embolism in the elderly. Arch Intern Med. 1996;156(20):2343–7.
Faber DR, de Groot PG, Visseren FL. Role of adipose tissue in haemostasis, coagulation and fibrinolysis. Obes Rev. 2009;10(5):554–63.
Rees DC, Cox M, Clegg JB. World distribution of factor V Leiden. Lancet. 1995;346(8983): 1133–4.
Juul K, Tybjaerg-Hansen A, Schnohr P, Nordestgaard BG. Factor V Leiden and the risk for venous thromboembolism in the adult Danish population. Ann Intern Med. 2004;140(5): 330–7.
Ho WK, Hankey GJ, Quinlan DJ, Eikelboom JW. Risk of recurrent venous thromboembolism in patients with common thrombophilia: a systematic review. Arch Intern Med. 2006;166(7):729–36.
Weill-Engerer S, Meaume S, Lahlou A, et al. Risk factors for deep vein thrombosis in inpatients aged 65 and older: a case-control multicenter study. J Am Geriatr Soc. 2004;52(8): 1299–304.
Baron JA, Gridley G, Weiderpass E, Nyren O, Linet M. Venous thromboembolism and cancer. Lancet. 1998;351(9109):1077–80.
Rosendaal FR, Van Hylckama Vlieg A, Doggen CJ. Venous thrombosis in the elderly. J Thromb Haemost. 2007;5 Suppl 1:310–7.
Grady D, Wenger NK, Herrington D, et al. Postmenopausal hormone therapy increases risk for venous thromboembolic disease. The Heart and Estrogen/progestin Replacement Study. Ann Intern Med. 2000;132(9):689–96.
Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321–33.
Stein PD, Matta F. Acute pulmonary embolism. Curr Probl Cardiol. 2010;35(7):314–76.
van Belle A, Buller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, d-dimer testing, and computed tomography. JAMA. 2006;295(2):172–9.
Wells PS, Anderson DR, Rodger M, 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(3):416–20.
Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med. 2001;161(1): 92–7.
Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006;144(3):165–71.
Righini M, Bounameaux H. External validation and comparison of recently described prediction rules for suspected pulmonary embolism. Curr Opin Pulm Med. 2004;10(5):345–9.
Klok FA, Mos IC, Nijkeuter M, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008;168(19):2131–6.
Miniati M, Prediletto R, Formichi B, et al. Accuracy of clinical assessment in the diagnosis of pulmonary embolism. Am J Respir Crit Care Med. 1999;159(3):864–71.
Stein PD, Beemath A, Matta F, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007;120(10):871–9.
Timmons S, Kingston M, Hussain M, Kelly H, Liston R. Pulmonary embolism: differences in presentation between older and younger patients. Age Ageing. 2003;32(6):601–5.
Punukollu G, Gowda RM, Vasavada BC, Khan IA. Role of electrocardiography in identifying right ventricular dysfunction in acute pulmonary embolism. Am J Cardiol. 2005;96(3):450–2.
Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M. The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads – 80 case reports. Chest. 1997;111(3):537–43.
Geibel A, Zehender M, Kasper W, Olschewski M, Klima C, Konstantinides SV. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. Eur Respir J. 2005;25(5):843–8.
Stein PD, Gottschalk A, Saltzman HA, Terrin ML. Diagnosis of acute pulmonary embolism in the elderly. J Am Coll Cardiol. 1991;18(6):1452–7.
Masotti L, Ceccarelli E, Cappelli R, Guerrini M, Forconi S. Pulmonary embolism in the elderly: clinical, instrumental and laboratory aspects. Gerontology. 2000;46(4):205–11.
Ramos A, Murillas J, Mascias C, Carretero B, Portero JL. Influence of age on clinical presentation of acute pulmonary embolism. Arch Gerontol Geriatr. 2000;30(3):189–98.
Ceccarelli E, Masotti L, Barabesi L, Forconi S, Cappelli R. Pulmonary embolism in very old patients. Aging Clin Exp Res. 2003;15(2):117–22.
Kokturk N, Oguzulgen IK, Demir N, Demirel K, Ekim N. Differences in clinical presentation of pulmonary embolism in older vs younger patients. Circ J. 2005;69(8):981–6.
Stein PD, Saltzman HA, Weg JG. Clinical characteristics of patients with acute pulmonary embolism. Am J Cardiol. 1991;68(17):1723–4.
Elliott CG, Goldhaber SZ, Visani L, DeRosa M. Chest radiographs in acute pulmonary embolism. Results from the International Cooperative Pulmonary Embolism Registry. Chest. 2000;118(1):33–8.
Busby W, Bayer A, Pathy J. Pulmonary embolism in the elderly. Age Ageing. 1988;17(3): 205–9.
Le Gal G, Righini M, Roy PM, et al. Differential value of risk factors and clinical signs for diagnosing pulmonary embolism according to age. J Thromb Haemost. 2005;3(11):2457–64.
Rodger MA, Carrier M, Jones GN, et al. Diagnostic value of arterial blood gas measurement in suspected pulmonary embolism. Am J Respir Crit Care Med. 2000;162(6):2105–8.
Stein PD, Terrin ML, Hales CA, et al. Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest. 1991;100(3):598–603.
Masotti L, Ray P, Righini M, et al. Pulmonary embolism in the elderly: a review on clinical, instrumental and laboratory presentation. Vasc Health Risk Manag. 2008;4(3):629–36.
Libby P, Braunwald E. Braunwald’s heart disease: a textbook of cardiovascular medicine. 8th ed. Philadelphia: Saunders/Elsevier; 2008.
Karami-Djurabi R, Klok FA, Kooiman J, Velthuis SI, Nijkeuter M, Huisman MV. d-Dimer testing in patients with suspected pulmonary embolism and impaired renal function. Am J Med. 2009;122(11):1050–3.
Perrier A, Roy PM, Sanchez O, et al. Multidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med. 2005;352(17):1760–8.
Righini M, Le Gal G, Perrier A, Bounameaux H. Effect of age on the assessment of clinical probability of pulmonary embolism by prediction rules. J Thromb Haemost. 2004;2(7): 1206–8.
Sohne M, Kamphuisen PW, van Mierlo PJ, Buller HR. Diagnostic strategy using a modified clinical decision rule and d-dimer test to rule out pulmonary embolism in elderly in- and outpatients. Thromb Haemost. 2005;94(1):206–10.
Stein PD, Hull RD, Patel KC, et al. d-Dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med. 2004;140(8):589–602.
Harper PL, Theakston E, Ahmed J, Ockelford P. d-dimer concentration increases with age reducing the clinical value of the d-dimer assay in the elderly. Intern Med J. 2007;37(9):607–13.
Righini M, Goehring C, Bounameaux H, Perrier A. Effects of age on the performance of common diagnostic tests for pulmonary embolism. Am J Med. 2000;109(5):357–61.
Le Gal G, Righini M, Sanchez O, et al. A positive compression ultrasonography of the lower limb veins is highly predictive of pulmonary embolism on computed tomography in suspected patients. Thromb Haemost. 2006;95(6):963–6.
Schoepf UJ, Goldhaber SZ, Costello P. Spiral computed tomography for acute pulmonary embolism. Circulation. 2004;109(18):2160–7.
Barrett BJ, Parfrey PS. Clinical practice. Preventing nephropathy induced by contrast medium. N Engl J Med. 2006;354(4):379–86.
Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators. JAMA. 1990;263(20):2753–9.
Sostman HD, Miniati M, Gottschalk A, Matta F, Stein PD, Pistolesi M. Sensitivity and specificity of perfusion scintigraphy combined with chest radiography for acute pulmonary embolism in PIOPED II. J Nucl Med. 2008;49(11):1741–8.
Bova C, Greco F, Misuraca G, et al. Diagnostic utility of echocardiography in patients with suspected pulmonary embolism. Am J Emerg Med. 2003;21(3):180–3.
Jaff MR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123(16): 1788–830.
Ray P, Maziere F, Medimagh S, et al. Evaluation of B-type natriuretic peptide to predict complicated pulmonary embolism in patients aged 65 years and older: brief report. Am J Emerg Med. 2006;24(5):603–7.
Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979–1998: an analysis using multiple-cause mortality data. Arch Intern Med. 2003;163(14): 1711–7.
Carson JL, Kelley MA, Duff A, et al. The clinical course of pulmonary embolism. N Engl J Med. 1992;326(19):1240–5.
Berman AR, Arnsten JH. Diagnosis and treatment of pulmonary embolism in the elderly. Clin Geriatr Med. 2003;19(1):157–75. viii.
Raschke RA, Gollihare B, Peirce JC. The effectiveness of implementing the weight-based heparin nomogram as a practice guideline. Arch Intern Med. 1996;156(15):1645–9.
Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism. A statement for healthcare professionals. Council on Thrombosis (in consultation with the Council on Cardiovascular Radiology), American Heart Association. Circulation. 1996;93(12):2212–45.
Campbell NR, Hull RD, Brant R, Hogan DB, Pineo GF, Raskob GE. Aging and heparin-related bleeding. Arch Intern Med. 1996;156(8):857–60.
Dinwoodey DL, Ansell JE. Heparins, low-molecular-weight heparins, and pentasaccharides: use in the older patient. Cardiol Clin. 2008;26(2):145–55. v.
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. Tinzaparine ou Heparine Standard: evaluations dans l’Embolie Pulmonaire. N Engl J Med. 1997;337(10):663–9.
Buller HR, Davidson BL, Decousus H, et al. Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med. 2003;349(18):1695–702.
Hirsh J, Guyatt G, Albers GW, Harrington R, Schunemann HJ. Executive summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):71S–109.
Gage BF, Yan Y, Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006;151(3): 713–9.
Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood. 2005;106(8): 2710–5.
Arcasoy SM, Kreit JW. Thrombolytic therapy of pulmonary embolism: a comprehensive review of current evidence. Chest. 1999;115(6):1695–707.
Stein PD, Alnas M, Skaf E, et al. Outcome and complications of retrievable inferior vena cava filters. Am J Cardiol. 2004;94(8):1090–3.
PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interruption Cave) randomized study. Circulation. 2005;112(3):416–22.
Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prevention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med. 1998;338(7):409–15.
White RH, Zhou H, Kim J, Romano PS. A population-based study of the effectiveness of inferior vena cava filter use among patients with venous thromboembolism. Arch Intern Med. 2000;160(13):2033–41.
Stein PD, Hull RD, Kayali F, Ghali WA, Alshab AK, Olson RE. Venous thromboembolism according to age: the impact of an aging population. Arch Intern Med. 2004;164(20):2260–5.
Spencer FA, Lessard D, Emery C, Reed G, Goldberg RJ. Venous thromboembolism in the outpatient setting. Arch Intern Med. 2007;167(14):1471–5.
Leizorovicz A, Cohen AT, Turpie AG, Olsson CG, Vaitkus PT, Goldhaber SZ. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation. 2004;110(7):874–9.
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Mathur, A., Sauler, M., Pisani, M. (2012). Pulmonary Embolism in Older Patients. In: Pisani, M. (eds) Aging and Lung Disease. Respiratory Medicine. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-60761-727-3_7
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