Pulmonary Embolism

  • Nages Nagaratnam
  • Kujan Nagaratnam
  • Gary Cheuk
Reference work entry


There is a marked discrepancy between the incidence of PE which is clinically diagnosed (1%) and autopsy findings in hospitalised patients (65%). This review highlights the improvements that have occurred in clinical care. Less than 30% of the PE is diagnosed on the index visit in the elderly. Restricted activity as in prolonged flights and prolonged rest or immobilisation and surgery pose enormous risk for developing deep vein thrombosis. In the elderly the diagnosis is often missed because of the non-specific and atypical presentation. The diagnosis of PE in the elderly is difficult because of the presence of cardiopulmonary comorbidities, and furthermore the characteristics of diagnostic tests for PE may be altered by age. A non-invasive diagnosis strategy combines clinical assessment, D-dimer estimation, ultrasonography and helical CT which yielded a diagnosis in 99% of outpatients suspected of PE.


Pulmonary embolism Deep vein thrombosis D-dimer estimation Helical CT Computed tomography pulmonary angiography 


  1. 1.
    Morell MT. The incidence of pulmonary embolism in the elderly. Geriatrics.1970;25:138–143.Google Scholar
  2. 2.
    Freiman DG, Suyemoto J, Wessler S. Frequency of pulmonary thromboembolism in man. N Eng J Med. 1965; 272:1278–1280.CrossRefGoogle Scholar
  3. 3.
    Leibovitz A, Blumenfeld O, Banmoehl Y, Segal R, Habot B. Postmortem examination on patients of a geriatric hospital. Aging Clin Exp Res. 2001;13:406–9.Google Scholar
  4. 4.
    Taubman LB, Silverstone FA,. Autopsy proven pulmonary embolism among the institutionalized elderly. J Am Geriatr Soc. 1986;34:752–756.CrossRefPubMedGoogle Scholar
  5. 5.
    DeMonaco NA, Dang Q, Kapoor WN, Ragni MV. Pulmonary embolism incidence is increasing with use of spiral computed tomography. Am J Med. 2008;121(7):611–7.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Carrier M, Righini M, Lee Gai G. Symptomatic subsegmental pulmonary embolism: what is the next step?. J Thrombo Haemost. 2012;10(8):1486–90 .CrossRefGoogle Scholar
  7. 7.
    Barrit W, Jordan SE. Anticoagulant drugs in the treatment of pulmonary embolism: a controlled trial. Lancet. 1960;1:1309–12.CrossRefGoogle Scholar
  8. 8.
    Garg K. Acute Pulmonary Embolism (Helical CT). eMedicine. accessed on 9/28/2008.
  9. 9.
    Dalen TE, Alpers JS. Natural history of pulmonary embolism. Prog Cardiovasc Dis. 1975;17:259–70.CrossRefPubMedGoogle Scholar
  10. 10.
    Van der Spuy JC. The surgical anatomy of the pulmonary vessels. Thorax 1953;8:89. Downloaded from on January 22 2014.
  11. 11.
    Stein PD, Gottschalk A, Saltzman HA, Terrin ML. Diagnosis of acute pulmonary embolism in the elderly. J Am Coll Cardiol. 1991;18:1452–1457.CrossRefPubMedGoogle Scholar
  12. 12.
    Ramos A, Murrilles J, Maseras C, Carretero MB, Portro JL. Influence of age on clinical presentation of acute pulmonary embolism. Arch Herontol Geriatr. 2000;30:189–198.CrossRefGoogle Scholar
  13. 13.
    Ceccarelli E, Masotti L, Barabesi L, Forconi S, Capelli R. Pulmonary embolism in very old patients. Aging Clin Exp Res. 2003;15:117–22.CrossRefPubMedGoogle Scholar
  14. 14.
    Masotti L, Ceccareli E, Capelli R,Guerrini M, Forconi S. Pulmonary embolism in the elderly clinical, instrumental and laboratory aspects. Gerontology. 2000;46:205–211.CrossRefPubMedGoogle Scholar
  15. 15.
    Girard P, Sanchez D, Leroyer C, Musset D, Meyer G, Stern JB, et al. Deep vein thrombosis in patients with acute pulmonary embolism: prevalence, risk factors and clinical significance. Chest. 2005,128:1593–600.Google Scholar
  16. 16.
    Masoti L, Ray P, Righini M, Le Gal G, Antonelli F, Landini G, et al. Pulmonary embolism in the elderly: a review on clinical instrumental and laboratory presentation. Vasc Health Risk Manag. 2008;4(3):629–636.CrossRefGoogle Scholar
  17. 17.
    Stein PD, Beemath H, Matta F, Weg JG, Yusen RD, Hales CA, et al. Clinical characteristics of patients of patients with pulmonary embolism: Data from PIOPEDII. Am J Med. 2007;120:871–879.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Kokturk N, Ognzulgen IK, Demir N, Demirel K, Ekim N. Differences in clinical presentation of pulmonary presentation on older vs younger patients. Circ J. 2005;69(8):981–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Punukollu H, Kahn IA, Punukollu G, Gowda RM, Mendoza C, Sacchi TJ. Acute pulmonary embolism in elderly: clinical characteristics and outcome. Int J Cardiology. 2005; 99:213–16.CrossRefGoogle Scholar
  20. 20.
    Righini M, LeGal G, Perrier A, Bruameaux H. The challenge of diagnosing pulmonary embolism in elderly patients: influence of age on commonly used diagnostic tests and strategies. J Am Geriatr Soc. 2005;53:1039–1045.CrossRefPubMedGoogle Scholar
  21. 21.
    Mispelaere D, Gierant JC, Audebert TM, Remond A, Sevestre-Pietri MA, Jounieax V. Pulmonary embolism and sibilant types of chronic obstructive airways disease decompensation. Rev Mal Respir. 2002;19:415–23.PubMedGoogle Scholar
  22. 22.
    Kucher N, Printzen G, Goldhaber SZ. Prognostic role of brain natriuretic peptide in acute pulmonary embolism. Circulation. 2003;107: 2545–49.CrossRefPubMedGoogle Scholar
  23. 23.
    Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging, management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med. 2001;135:98–107.CrossRefPubMedGoogle Scholar
  24. 24.
    Qaseem A, Snow A, Barry P, Hornbake ER, Rodnick JE, Tobolc T, et al. Current diagnosis of venous thromboembolism in primary care: A clinical practice guideline from the American Academy of Family Physicians of American College of Physicians. Am Fam Med. 2007;5:57–62.CrossRefGoogle Scholar
  25. 25.
    Garg K, Macey L. Helical CT scanning in the diagnosis of pulmonary embolism. Respiration. 2003:70:231–237.CrossRefPubMedGoogle Scholar
  26. 26.
    Rathbun SW, Raskob GE, Whitsett TL. Sensitivity and specificity of helical CT in the diagnosis of pulmonary embolism: a systematic review. Ann Intern Med. 2000;132: 27–232.CrossRefGoogle Scholar
  27. 27.
    Wiener RS, Schwartz LM ,Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171(9):831–7.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Perrier A, Roy P-M, Aujesky D, Chagnon I, Howarth N, Gourdier AL, et al. Pulmonary embolism in outpatients eith clinical assessment, D-Dimer measurement, venous ultrasound and helical CT: A multicentre management study. Am J Med. 2004;116:291–299.CrossRefPubMedGoogle Scholar
  29. 29.
    Donnamaria V, Palla A, Giuntini C. Gender, age and clinical signs of patients suspected of pulmonary embolism. Respiration. 1994;61–67.Google Scholar
  30. 30.
    Task Force on Pulmonary Embolism. European Society of Cardiology. Guidelines on diagnosis and management of acute pulmonary embolism. Eur Heart J. 2000; 21:1301–36.CrossRefGoogle Scholar
  31. 31.
    Goldhaber SZ. Modern treatment of pulmonary embolism. Eur Respir J. Suppl 2002;35:22s–27s.CrossRefPubMedGoogle Scholar
  32. 32.
    Kucher N,Goldhaber SZ. Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Ciculation. 2003;108 (15):2191–4.CrossRefGoogle Scholar
  33. 33.
    Timmons S, Kingston M, Hussen M, Kelly H, Listae R. Pulmonary embolism: differences in presentation between older and younger patients,. Age Ageing. 2013;32:601–605.CrossRefGoogle Scholar
  34. 34.
    Ceccarelli E, Masotti L, Barabesi L, Forconi S, Cappelli R. Pulmonary embolism in very old patients. Aging Clin Exp Res. 2013;15(2):117–22.CrossRefGoogle Scholar
  35. 35.
    Castelli R, Bucciarelli P, Porro P, Depetri F, Cugno M. Pulmonary embolism in elderly patients: prognostic impact of Cumulative Illness Rating Scale (IRS) on short term mortality. Thromb Res. 2014;134(2):326–30.CrossRefPubMedGoogle Scholar
  36. 36.
    Ray P, Birollenu S, Lefort Y, Bequemin MH, Beyelman C, Isnard R, et al. Acute respiratory failure in the elderly, etiology emergency diagnosis and prognosis. Crit Care. 2006;19 R82.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Nages Nagaratnam
    • 1
  • Kujan Nagaratnam
    • 1
  • Gary Cheuk
    • 2
  1. 1.The University of SydneyWestmead Clinical SchoolWestmeadAustralia
  2. 2.Rehabilitation and Aged Care ServiceBlacktown-Mt Druitt HospitalMount DruittAustralia

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