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High-risk factors in pulmonary embolism that predict poor prognosis

High-risk factors in pulmonary embolism that predict poor prognosis
  • Persistent hypotension* or shock despite adequate resuscitation
  • New or worsening RV dysfunction by any 1 or combination of the following:
    • Echocardiography (eg, enlarged RV, increased RV/LV ratio ≥1, bulging of the RV septum into the LV, reduced RV ejection fraction)
    • Chest CT (eg, enlarged RV, increased RV/LV ratio, contrast observed in the liver)
    • Elevated biomarkers, including troponin and BNP
    • Absence of comorbidities that affect RV function (eg, significant left-sided heart disease or known poor RV function from chronic lung disease, or septic shock)
  • An sPESI ≥1Δ
  • A high clot burden (eg, >70% perfusion deficit)◊
  • Proximal deep venous thrombosis in the lower extremities
  • Significant hypoxemia (eg, <90%) and/or respiratory distress
  • Tachycardia >120 beats per minute
  • Poor cardiopulmonary reserve§
  • The presence of right-sided cardiac thrombus (ie, clot-in-transit; thrombus in inferior vena cava, right atrium, RV, or left atrium [if a patent foramen ovale is present])
Other than refractory hypotension and shock due to acute PE in patients with a low bleeding risk, none of the listed factors by itself is an absolute indication for thrombolytic therapy. Rather, all factors are considered collectively so that the risk of death from PE can be assessed appropriately. Other reported factors include hyponatremia, elevated lactate and white cell count, poor performance, and older age >65 years.

BNP: brain natriuretic peptide; BP: blood pressure; CT: computed tomography; LV: left ventricle; PE: pulmonary embolism; RV: right ventricle; sPESI: simplified pulmonary embolism index.

* Clinically significant hypotension is defined as a systolic BP <90 mmHg or hypotension that requires vasopressors or inotropic support despite adequate filling status in combination with end-organ hypoperfusion; persistent hypotension or a drop in systolic BP of ≥40 mmHg from baseline for a period >15 minutes; hypotension is not explained by other causes such as hypovolemia, sepsis, arrhythmia, or left ventricular dysfunction from acute myocardial ischemia or infarction.

¶ Other than contrast in the liver, chest CT is imprecise for RV assessment, especially when compared with echocardiography. In most cases, if feasible, CT findings of RV enlargement should prompt echocardiography.

Δ An sPESI score is calculated based upon a cumulative point system for age >80 years (1 point), history of cancer (1 point), chronic cardiopulmonary disease (1 point), pulse ≥110/minute (1 point), systolic BP <100 mmHg (1 point), and arterial oxygen saturation <90% (1 point); low-risk PE is a score of 0 while high-risk is any score >0.

◊ Although the obstruction index can be calculated, it is not a routine readout by radiologists and is more likely to be estimated gestalt.

§ Small PE in patients with limited cardiopulmonary reserve may precipitate RV dysfunction and cardiac arrest.
Graphic 127558 Version 4.0

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