Patients for Thrombolysis

  • Carlos Jerjes-SánchezEmail author
  • Pedro Gutierrez Fajardo


Acute pulmonary embolism remains the third most frequent cardiovascular disease after acute coronary syndrome and stroke. Their severity related with death risk demand an expeditious approach to risk stratification and diagnosis to determine immediate treatment to reduce morbidity and mortality. Different calculation scores are available to avoid delay in clinical stratification. A careful analysis based on experience of risk factors, clinical symptoms and signs, electrocardiogram and chest X-ray findings allows for a high-clinical suspicion cardiac biomarkers and noninvasive imaging techniques are used to determine right ventricle status and pulmonary vascular obstruction, important components in choosing a treatment according to patient’s risk. Right ventricular dysfunction by image techniques and/or ventricular dysfunction biomarkers and/or acute cellular damage identify objectively high-risk patient. However, despite all technology that we have, high-clinical suspicion remains on clinical bases.


Pulmonary embolism Risk stratification Diagnosis Noninvasive imaging Echocardiography 


  1. 1.
    Wood KE. Major pulmonary embolism. Chest. 2002;121:877–905.CrossRefPubMedGoogle Scholar
  2. 2.
    Horlander KT, Mannino DM, Leeper Schcreiber KV. Pulmonary embolism in the United States, 1979-1998: an analysis using multiple cause-mortality data. Arch Intern Med. 2003;163:1711–17.CrossRefPubMedGoogle Scholar
  3. 3.
    Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, Greer IA, Heit JA, Hutchinson JL, Kakkar AK, Mottier D, Oger E, Samama MM, Spangl M. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007;98:756–64.PubMedGoogle Scholar
  4. 4.
    Anderson Jr FA, Spencer FA. Risk factors for venous thromboembolism. Circulation. 2003;107:19S–16.CrossRefGoogle Scholar
  5. 5.
    Stein PD, Henry JW. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy. Chest. 1995;108:978–81.CrossRefPubMedGoogle Scholar
  6. 6.
    Kyrle PA, Rosendaal FR, Eichinger S. Risk assessment for recurrent venous thrombosis. Lancet. 2010;376:2032–39.CrossRefPubMedGoogle Scholar
  7. 7.
    Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galie N, Gibss JSR, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noodergraff A, Zamorano JL, Zampotari M. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology. Eur Heart J. 2014;35:3033–80.CrossRefPubMedGoogle Scholar
  8. 8.
    Pollack CV, Schcreiber D, Goldhaber SZ, Slattery D, Fanikos J, O’Neil BJ, Thompson JR, Hiestand B, Briese BA, Pendleton RC, Miller CD, Kline JA. Clinical characteristics, management and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the real world registry). J Am Coll Cardiol. 2011;57:700–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Squizzato A, Kuciani D, Rubboli A, Di Gennaro L, Landolfi R, De Luca C, Porro F, Moia M, Testa S, Imberti D, Bertolini G. Differential diagnosis of pulmonary embolism in outpatients with non-specific cardiopulmonary symptoms. Intern Emerg Med. 2013;8:695–702.CrossRefPubMedGoogle Scholar
  10. 10.
    Anderson Jr FA, Spencer FA. Risk factors for venous thromboembolism. Circulation. 2003;107:I9–15.CrossRefPubMedGoogle Scholar
  11. 11.
    Rogers MA, Levine DA, Blumberg N, Flanders SA, Chopra V, Langa KM. Triggers of hospitalization for venous thromboembolism. Circulation. 2012;125:2092–99.PubMedCentralCrossRefPubMedGoogle Scholar
  12. 12.
    Vanderbroucke JP, Rosing J, Bloemenkamp KWM, Middeldorp S, Helmerhorst FM, Bouma BN, Rosendaal F. Oral contraceptives and the risk of venous thrombosis. N Engl J Med. 2001;344:1527–35.CrossRefGoogle Scholar
  13. 13.
    Blanco-Molina A, Rotta LL, DiMicco P, Brenner B, Trujillo-Santos J, Ruiz-Gamietea A, Monreal M. Venous thromboembolism during pregnancy, postpartum or during contraceptive use. Thromb Haemost. 2010;103:306–11.CrossRefPubMedGoogle Scholar
  14. 14.
    Pomp ER, Leselnik AM, Rosendaal FR, Doggen JM. Pregnancy, the postpartum period and prothrombotic defects: risk of venous thrombosis in the MEGA study. J Thromb Haemost. 2008;6:632–37.CrossRefPubMedGoogle Scholar
  15. 15.
    Jerjes-Sánchez C. Pulmonary embolism. From molecular basis to clinical practice. In: Wright NJ, Smith A, editors. Pulmonary embolism: causes, symptoms and treatment, Pulmonary and respiratory diseases and disorders. Hauppauge: Nova; 2012. p. 1–20.Google Scholar
  16. 16.
    Wicki J, Perrier A, Perneger TV, Bounameaux H, Junod AF. Predicting adverse outcome in patients with acute pulmonary embolism: a risk score. Thromb Haemost. 2000;84:548–52.PubMedGoogle Scholar
  17. 17.
    Zhou XY, Ben SQ, Chen HL, Ni SS. The prognostic value of pulmonary embolism severity index in acute pulmonary embolism: a meta-analysis. Respir Res. 2012;4:111–122.Google Scholar
  18. 18.
    Venet C, Jimenez D, Mean M, Aujesky D. A comparison of the original and simplified Pulmonary Embolism Severity Index. Thromb Haemost. 2011;106:423–28.CrossRefGoogle Scholar
  19. 19.
    Zhong-Qun Z, Chong-Quan W, Nikus KC, Sclarovsky S. A new electrocardiogram finding for massive pulmonary embolism: ST elevation in lead aVR with ST depression in leads I and V4 to V6. AJEM. 2013;31:456.e5–8.CrossRefGoogle Scholar
  20. 20.
    Janata K, Höchtl T, Wenzel C, Jarai R, Fellner B, Geppert A, Smetana P, Havranek V, Huber K. The role of ST-segment elevation in lead aVR in the risk assessment of patients with acute pulmonary embolism. Clin Res Cardiol. 2012;101:329–37.CrossRefPubMedGoogle Scholar
  21. 21.
    Wong C-K, Gao W, Stewart RAH, Benatar J, French JK, Aylward PEG, White HD, for the HERO-2 Investigators. aVR ST elevation: an important but neglected sign in ST elevation acute myocardial infarction. Eur Heart J. 2010;31:1845–53.PubMedCentralCrossRefPubMedGoogle Scholar
  22. 22.
    Kucher N, Walpoth N, Wustmann K, Novenu M, Gertsch M. QR in V1—and ECG sign associated with right ventricular strain and adverse clinical outcome in pulmonary embolism. Eur Heart J. 2003;24:107–19.Google Scholar
  23. 23.
    Reyes E, Jerjes-Sanchez C, Ramirez-Rivera A, Gutierrez-Fajardo P, Garza A, Decanini H, Cantú F. Valor predictivo de qR asociado a desnivel positivo del segmento ST-T en V1 para el diagnóstico de infarto del ventrículo derecho secundario a TEP. Arch Inst Cardiol Mex. 1997;6:148.Google Scholar
  24. 24.
    Jerjes-Sanchez C, Ramirez-Rivera A, Gonzalez CVM, Garcia CA. Tromboembolia pulmonar masiva con desviación del eje eléctrico a la derecha y bajo voltaje. Arch Cardiol Mex. 1987;57:301–5.Google Scholar
  25. 25.
    Adelasis J, Morge J, Alberca D, Grenho MF, Arroja I, Aleixo AM. Electrocardiographic presentation of massive and submassive pulmonary embolism. Rev Port Cardiol. 2008;27:591–610.Google Scholar
  26. 26.
    Stein PD, Dalen JE, McIntyre KM, Sasahara MM, Wnger NK, Willis PW. The electrocardiogram in acute pulmonary embolism. Prog Cardiovasc Dis. 1975;17:247–57.CrossRefPubMedGoogle Scholar
  27. 27.
    Jerjes-Sanchez C, Ramirez-Rivera A, Ibarra-Perez C. Pulmonary embolism and bradycardia. Interconti Cardiol. 1996;5:27–9.Google Scholar
  28. 28.
    Campbell IA, Fennerty A, Miller AC, Baglin T, Gibss S, Hansel D, Reid J, Bonameux H, Remy-Jardin M, Wells P. British Thoracic Society Guidelines for the management of suspected acute pulmonary embolism. Thorax. 2003;58:470–84.CrossRefGoogle Scholar
  29. 29.
    Jerjes-Sanchez DC, Elizalde-Gonzalez JJ, Sandoval-Zarate J, Gutierrez-Fajardo P, Seoane M, Ramirez-Rivera A, Pulido T, Beltran M, Santos E, Bautista E, Ibarra-Perez C, Arriaga-Nava R. Diagnostico, estratificación y tratamiento de la tromboembolia pulmonar aguda. Guias y Recomendaciones del Capitulo de Circulacion Pulmonar de la Sociedad Mexicana de Cardiologia. Arch Cardiol Mex. 2004;74:S547–85.Google Scholar
  30. 30.
    Laporte S, Mismetti P, DecousUS H, Uresandi F, Otero R, Lobo JL, Monreal M. Clinical predictors for fatal pulmonary embolism in 15520 patients with venous thromboembolism: findings from the Registro Informatizado de la Enfermedad TromboEmbolica Venosa (RIETE) Registry. Circulation. 2008;117:1711–16.CrossRefPubMedGoogle Scholar
  31. 31.
    Jaff MR, McCurtry MS, Archer SL, Cushman M, Goldbenger N, Golhaber SZ, Jenkins JS, Kline JA, Michaelis AD, Thistlewaite P, Vedantham S, White RJ, Zierler BK. Management of massive and submassive pulmonary embolism, iliofemoral deep venous thrombosis and chronic thrombotic pulmonary hypertension: a scientific statement from American Heart Association. Circulation. 2012;125:1788–830.Google Scholar
  32. 32.
    Lualdi JC, Goldhaber SZ. Right ventricular dysfunction after acute pulmonary embolism: pathophysiologic factors, detection, and therapeutic implications. Am Heart J. 1995;130:1276–82.CrossRefPubMedGoogle Scholar
  33. 33.
    Konstantinides S. Pulmonary embolism: impact of right ventricular dysfunction. Curr Opin Cardiol. 2005;20:496–501.CrossRefPubMedGoogle Scholar
  34. 34.
    Grignola JC, Gines F. Mecanica del ventriculo derecho. Actas Fisiologia. 2000;6:131–63.Google Scholar
  35. 35.
    Bleeker GB, Steendijk P, Holman ER, Yu CM, Breithardt OA, Kaandorp TAM, Shalij MJ, van der Wall EE, Bax JJ, Nihonyannopoulos P. Acquired right ventricular dysfunction. Heart. 2006;92:i14–8.PubMedCentralCrossRefPubMedGoogle Scholar
  36. 36.
    Chung T, Emmet L, Mansber R, Peters M, Kritharides L. Natural history of right ventricular dysfunction after acute pulmonary embolism. J Am Soc Echocardiogr. 2007;20:885–94.CrossRefPubMedGoogle Scholar
  37. 37.
    Dell’Italia LJ. Anatomy and physiology of the right ventricle. Cardiol Clin. 2012;30:167–87.CrossRefPubMedGoogle Scholar
  38. 38.
    Gianitis E, Muller-Bardoff M, Kurowski V, Weidtmann B, Wiegand U, Kampan M, Katus HA. Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism. Circulation. 2000;102:211–7.CrossRefGoogle Scholar
  39. 39.
    Konstantinides S, Geibel A, Olschewski M, Kasper W, Hruska N, Jacle S, Binder L. Importance of cardiac troponin T I and T in risk stratification of patients with acute pulmonary embolism. Circulation. 2002;106:1263–8.CrossRefPubMedGoogle Scholar
  40. 40.
    ten Wolde M, Tulevski II, Mulder JWM, Shone M, Boosma F, Mulder BJM, Buller HR. Brain natriuretic peptide as a predictor of adverse outcome in patients with pulmonary embolism. Circulation. 2003;86:2082–4.CrossRefGoogle Scholar
  41. 41.
    Kucher N, Goldhaber SZ. Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Circulation. 2003;108:2191–94.CrossRefPubMedGoogle Scholar
  42. 42.
    Kucher N, Printzen G, Goldhaber SZ. Prognostic role of brain natriuretic peptide in acute pulmonary embolism. Circulation. 2003;107:2545–47.CrossRefPubMedGoogle Scholar
  43. 43.
    Pruszczyk P, Bochowicz A, Torbicki A, Szulc M, Kurzyna M, Fijalkowska A, Kuch-Wocial A. Cardiac troponin T monitoring identifies high-risk group of normotensive patients with acute pulmonary embolism. Chest. 2003;123:1947–52.CrossRefPubMedGoogle Scholar
  44. 44.
    Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency room department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135:98–107.CrossRefPubMedGoogle Scholar
  45. 45.
    Righini M, Van EJ, den Exter PL, Roy PM, Verschuren F, Ghuysen A, Rutschman OT, Sanchez O, Jaffrelot M, Trinh-Duc A, Le Gall C, Mustafa PM, van Kralingen KW, Grootenboers MJ, Durian MF, Cheung YW, Meyer G, Bounameux H, Huisman MV, Kamphuisen PE, Le Gal G. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST PE study. JAMA. 2014;311:1117–24.CrossRefPubMedGoogle Scholar
  46. 46.
    Chabloz P, Reber G, Boehlen F, Hohlfeld P, de Moerloose P. TAFI antigen and D-dimer levels during normal pregnancy and at delivery. Br J Haematol. 2001;115:150–52.CrossRefPubMedGoogle Scholar
  47. 47.
    Righini M, Le Gall G, De Lucia S, Roy PM, Meyer G, Aujesky D, Bounameaux H, Perrier A. Clinical usefulness of D-dimer testing in cancer patients suspected pulmonary embolism. Thromb Haemost. 2006;95:715–19.PubMedGoogle Scholar
  48. 48.
    Di Nisio M, Squizzato A, Rutjes AWS, Buller HR, Zwinderman AH, Bossuyt PMM. Diagnostic accuracy of D-dimer test for exclusion of venous thromboembolism. A systematic review. J Thromb Haemost. 2007;5:296–304.CrossRefPubMedGoogle Scholar
  49. 49.
    Kucher N, Rossi E, de la Rosa M, Goldhaber SZ. Prognostic role of echocardiography in patients with acute PE and a systemic arterial pressure of 90 mmHg or higher. Arch Intern Med. 2005;165:1777–81.CrossRefPubMedGoogle Scholar
  50. 50.
    Jerjes Sanchez C, Gutierrez-Fajardo P, Ramírez-Rivera A. Qualitative echocardiographic stratification in pulmonary embolism: significance of inversion of diastolic right/left ventricles ratio. Chest. 1998;114:392S.Google Scholar
  51. 51.
    Jerjes Sanchez C, Gutierrez-Fajardo P, Ramírez-Rivera A, Hernandez-Chavez G. Infarto agudo del miocardio del ventriculo derecho secundario a tromboembolia pulmonary masiva. Arch Inst Cardiol Mex. 1995;65:65–73.PubMedGoogle Scholar
  52. 52.
    McConell MV, Solomon SD, Rayan ME. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78:469–73.CrossRefGoogle Scholar
  53. 53.
    van Belle A, Buller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW, Kramer MH, Kruip MJ, Kwakkel-van Erp JM, Leebeek FW, Nijkeuter M, Prins MH, Sohne M, Tick LW. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing and computed tomography. JAMA. 2006;295:172–79.CrossRefPubMedGoogle Scholar
  54. 54.
    Shoepf UJ, Costello P. CT angiography for diagnosis of pulmonary embolism: state of the art. Radiology. 2004;230:329–37.CrossRefGoogle Scholar
  55. 55.
    Perrier A, Roy PM, Sanchez O, Le Gal G, Meyer G, Gourdier AL, Furber A, Revel MP, Howarth N, Davido A, Bounameaux H. Multidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med. 2005;352:1760–68.CrossRefPubMedGoogle Scholar
  56. 56.
    Wiener RS, Schartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2001;171:831–37.Google Scholar
  57. 57.
    Carrier M, Righini M, Wells PS, Perrier A, Anderson DR, Rodger A, Pleasance S, Le Gal G. Subsegmental pulmonary diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. J Thromb Haemost. 2010;8:1716–22.CrossRefPubMedGoogle Scholar
  58. 58.
    Zhang LJ, Zhou CS, Schoepf UJ, Sheng HX, Wu CY, Krazinski AW, Silverman JR, Meinel FG, Zhao YE, Zhang ZJ, Lu GM. Dual-energy CT lung ventilation/perfusion imaging for diagnosing pulmonary embolism. Eur Radiol. 2013;23:2666–75.CrossRefPubMedGoogle Scholar
  59. 59.
    Sostman HD, Layish DT, Tapson VF, Spritzer CE, Delong DM, Trotter RTP, Macfall JR, Patz EF, Goodman PC, Wodard PK, Foo TKF, Farber JL. Prospective comparison of helical CT and MR imaging in clinically suspected acute pulmonary embolism. J Magn Reson Imaging. 1996;6:275–81.CrossRefPubMedGoogle Scholar
  60. 60.
    van Beek EJR, Wild JM, Fink C, Moody AR, Kauczor H-U, Oudkerk M. MRI for the diagnosis of pulmonary embolism. J Magn Reson Imaging. 2003;18:627–40.CrossRefPubMedGoogle Scholar
  61. 61.
    Hochhegger B, Ley-zaporozhan J, Marchiori E, Irion K, Soares Souza Jr A, Moreira J, Kaucsor HU, Ley S. Magnetic resonance imaging findings in acute pulmonary embolism. Br J Radiol. 2011;84:282–7.PubMedCentralCrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  • Carlos Jerjes-Sánchez
    • 1
    • 2
    • 3
    Email author
  • Pedro Gutierrez Fajardo
    • 4
  1. 1.Instituto de Cardiologia y Medicina Vascular, TEC SaludSan Pedro Garza GarciaMexico
  2. 2.Escuela de Medicina, Tecnológico de MonterreySan Pedro Garza GarciaMexico
  3. 3.Unidad de Investigacion Clinica en Medicina SCMonterreyMexico
  4. 4.Echocardiography LaboratoryHospital Bernardette, Instituto Cardiovascular de GuadalajaraJaliscoMexico

Personalised recommendations