Clinical course and prognosis of acute pulmonary embolism

  • S. Konstantinides
  • A. Geibel
  • W. Kasper


Effective treatment of acute pulmonary embolism (PE) requires prompt identification of patients at high risk of death or severe cardiovascular complications during the hospital stay. Determination of prognostic parameters in this heterogeneous patient population is far more important than calculation of a crude mortality rate due to PE. The multicenter Management Strategy and Prognosis in Pulmonary Embolism Registry examined the in-hospital clinical course of 1001 consecutive patients with acute PE. Overall mortality was 22 %, with 91 % of deaths directly related to PE. Clinical signs of acute right heart failure due to major PE (arterial hypotension, shock, circulatory collapse) were clearly associated with an adverse outcome. Mortality ranged from 8 to 65 % depending on the severity of clinical instability at presentation. Importantly, a significantly increased death rate was also observed in patients with echocardiographi-cally detected right ventricular dilation (84 vs. 16 %), a reliable noninvasive index of impending right heart failure. The independent prognostic effect of this finding was confirmed by multivariate analysis (Odds Ratio, 2.44; P = 0.004). Thus, the combination of clinical and echocardiographic findings permits accurate risk stratification of patients with acute PE. Evidence is also accumulating that these prognostic factors can be used to identify candidates for early thombolytic treatment.

Key words

Pulmonary embolism echocardiography prognosis mortality thrombolysis 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Alpert JS, Smith R, Carlson J, Ockene IS, Dexter L, Dalen JE (1976) Mortality in patients treated for pulmonary embolism. JAMA 236:1477–1480PubMedCrossRefGoogle Scholar
  2. 2.
    Cannon CP, Goldhaber SZ (1996) Cardiovascular risk stratification of pulmonary embolism. Am J Cardiol 78:1149–1151PubMedCrossRefGoogle Scholar
  3. 3.
    Carson JL, Kelley MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, Schwartz S, Thompson BT, Popovich J, Hobbins TE, Spera MA, Alavi A, Terrin ML (1992) The clinical course of pulmonary embolism. N Engl J Med 326:1240–1245PubMedCrossRefGoogle Scholar
  4. 4.
    Dalla-Volta S, Palla A, Santolicandro A, Giuntini C, Pengo V, Visioli O, Zonzin P, Zanuttini D, Barbaresi F, Agnelli G, Morpurgo M, Marini MG, Visani L (1992) PAIMS 2: Alteplase combined with heparin versus heparin in the treatment of acute pulmonary embolism. Plasminogen Activator Italian Multicenter Study 2. J Am Coll Cardiol 20:520–526PubMedCrossRefGoogle Scholar
  5. 5.
    Goldhaber SZ, Vaughan DE, Markis JE, Selwyn AP, Meyerovitz MF, Loscalzo J, Soo Kim D, Kessler CM, Dawley DL, Sharma GVRK, Sasahara A, Grossbard EB, Braunwald E (1986) Acute pulmonary embolism treated with tissue plasminogen activator. Lancet 2:886–889PubMedCrossRefGoogle Scholar
  6. 6.
    Goldhaber SZ, Haire WD, Feldstein ML, Miller M, Toltzis R, Smith JL, Taveira da Silva AM, Come PC, Lee RT, Parker JA, Mogtader A, McDonough TJ, Braunwald E (1993) Alteplase versus heparin in acute pulmonary embolism: Randomised trial assessing right-ventricular function and pulmonary perfusion. Lancet 341: 507–511PubMedCrossRefGoogle Scholar
  7. 7.
    Gulba DC, Schmid C, Borst HG, Lichtlen P, Dietz R, Luft FC (1994) Medical compared with surgical treatment for massive pulmonary embolism. Lancet 343: 576–577PubMedCrossRefGoogle Scholar
  8. 8.
    Hall RJC, Sutton GC, Kerr IH (1977) Long-term prognosis of treated acute massive pulmonary embolism. Br Heart J 39:1128–1134PubMedCrossRefGoogle Scholar
  9. 9.
    Hirsh J, Gale GS, McDonald IG, McCarthy RA, Pitt A (1968) Streptokinase therapy in acute major pulmonary embolism: Effectiveness and problems. Br Med J 4:729–734PubMedCrossRefGoogle Scholar
  10. 10.
    Hull RD, Raskob GE, Coates G, Panju AA, Gill GJ (1989) A new noninvasive management strategy for patients with suspected pulmonary embolism. Arch Intern Med 149:2549–2555PubMedCrossRefGoogle Scholar
  11. 11.
    Kasper W, Meinertz T, Henkel B, Eissner D, Hahn K, Hofmann T, Zeiher A, Just H (1986) Echocardiographic findings in patients with proven pulmonary embolism. Am Heart J 112:1284–1290PubMedCrossRefGoogle Scholar
  12. 12.
    Kasper W, Geibel A, Tiede N, Bassenge D, Kauder E, Konstantinides S, Meinertz T, Just H (1993) Distinguishing between acute and subacute massive pulmonary embolism by conventional and Doppler echocardiography. Br Heart J 70: 352–356PubMedCrossRefGoogle Scholar
  13. 13.
    Kasper W, Konstantinides S, Geibel A, Tiede N, Krause T, Just H (1997) Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism. Heart 77:346–349PubMedGoogle Scholar
  14. 14.
    Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, Rauber K, Iversen S, Redecker M, Kienast J, Just H, Kasper W (1997) Association between thrombolytic treatment and the prognosis of hemody-namically stable patients with major pulmonary embolism: Results of a multicenter registry. Circulation 96:882–888PubMedGoogle Scholar
  15. 15.
    Lilienfeld DE, Chan E, Ehland J, Godbold JH, Landrigan PJ, Marsh G (1990) Mortality from pulmonary embolism in the United States: 1962 to 1984. Chest 98:1067–1072PubMedCrossRefGoogle Scholar
  16. 16.
    Lindblad B, Sternby NH, Bergquist D (1991) Incidence of venous thromboembolism verified by necropsy over 30 years. Br Med J 302:709–711CrossRefGoogle Scholar
  17. 17.
    Lualdi JC, Goldhaber SZ (1995) Right ventricular dysfunction after acute pulmonary embolism: Pathophysiologic factors, detection, and therapeutic implications. Am Heart J 130:1276–1282PubMedCrossRefGoogle Scholar
  18. 18.
    Miller AH, Sutton GC, Kerr IH, Gibson RV, Honey M (1971) Comparison of streptokinase and heparin in treatment of isolated acute massive pulmonary embolism. Br Med J 2:681–684PubMedCrossRefGoogle Scholar
  19. 19.
    Research Committee of the British Thoracic Society (1992) Optimum duration of anticoagulation for deep-vein thrombosis and pulmonary embolism. Lancet 340:873–876Google Scholar
  20. 20.
    Stein PD, Hull RD, Raskob G (1994) Risks for major bleeding from thrombolytic therapy in patients with acute pulmonary embolism. Ann Intern Med 121:313–317PubMedGoogle Scholar
  21. 21.
    Urokinase in Pulmonary Embolism Trial: phase 1 results: a cooperative study (1970) JAMA 214:2163–2172CrossRefGoogle Scholar
  22. 22.
    Urokinase in Pulmonary Embolism Trial: phase 2 results: a cooperative study (1974) JAMA 229:1606–1613CrossRefGoogle Scholar
  23. 23.
    Verstraete M(1995) Thrombolytic treatment. Br Med J 311:582–583Google Scholar

Copyright information

© Dr. Dietrich Steinkopff Verlag GmbH & Co. KG, Darmstadt 2000

Authors and Affiliations

  • S. Konstantinides
    • 1
  • A. Geibel
    • 1
  • W. Kasper
    • 2
  1. 1.Zentrum Innere Medizin, Abteilung Kardiologie und PneumologieKlinikum der Georg-August-UniversitätGöttingenGermany
  2. 2.Medizinische KlinikSt. Josefs-Hospital WiesbadenWiesbadenGermany

Personalised recommendations