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Acute pulmonary embolism

Pulmonary embolism (PE) is a diagnosis of frequent presentation in the emergency department. It can present with classic features, such as dyspnea and pleuritic chest pain, but also less characteristically, for example, with insidious shortness of breath that starts for days to weeks, or syncope, with relatively few respiratory symptoms.

Therefore, physicians should have a high index of suspicion of PD in patients with cardiopulmonary symptoms, since the consequences of the lack of diagnosis or its delay can be serious.

As in most other areas of medicine, a large protocol has been developed for the diagnosis and management of PE, but there are still many gray areas in decision-making, requiring both clinical experience and decision-making.

How is your Diagnosis?

The algorithms and diagnostic techniques have not undergone many changes in the last 10 years, being the main diagnostic tool, pulmonary angiography by computed tomography (PACT).

Because PACT involves the use of ionizing radiation, its use is not appropriate for all suspected cases of PE, hence the use of d-dimer to select those patients with low probability of PE.

While there are several clinical probability scoring systems, the Wells score remains the most widely used international reference algorithm.

When the clinical probability of PE is low, a normal d-dimer has a high negative predictive value to exclude PE, but when there is an increase in d-dimer or the probability of PE is high, a diagnostic image must be made.

However, there is increasing interest in the use of age-adjusted d-dimer. The evidence has not yet reached enough importance to be considered part of routine practice.

In certain circumstances, in particular pregnancy, inflammation and cancer, d-dimer can not be used to classify patients for imaging.

An alternative strategy to CT is when you have to avoid ionizing radiation, it is the use of the Eco-Doppler of the veins of the legs, as it happens in pregnant women, but, in the absence of pregnancy, this strategy does not have enough performance to justify its use, since the positive findings are approximately 1 in 10 cases.

When the chest radiograph is normal, ventilation / perfusion (VQ) scanning can be used, with half the dose, also being an option for pregnant women.

With the advancement of technology, APTC can detect smaller filling defects of the pulmonary circulation. If the physician is certain that these filling defects are genuine pulmonary embolisms, it becomes important, because it allows him to assess whether such small clots have an influence on the presentation, for example, if they are in an isolated subsegment or the PE is sufficient as to cause a syncope.

Given the importance of the consequences of the diagnosis of PE, such as the need for lifelong anticoagulation, it is essential that in these circumstances scans be carefully reviewed and, sometimes, consider their repetition or opt for a different modality.

What is your treatment?

The mainstay of the treatment of PE is anticoagulation. Until recently, the standard of care was low molecular weight heparin (LMWH) followed by warfarin, but in recent years it has been replaced by direct oral anticoagulants (ODA).

Apixaban, dabigatran, edoxaban and rivaroxaban have been licensed for the treatment of venous thromboembolism.

Dabigatran and edoxaban require a minimum entry period of 5 days with LMWH, while apixaban and rivaroxaban can be administered as soon as PE has been confirmed, with an initial high-dose regimen that at 7 and 21 days , respectively, are reduced.

When anticoagulation is contraindicated because of a high risk of bleeding, filters of the inferior vena cava can be used, but it is important to eliminate them as soon as anticoagulation is possible, due to the risk of long-term complications. There are no other routine indications for the use of these filters.

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