Prognostic stratification of acute pulmonary embolism: focus on clinical aspects, imaging, and biomarkers

Abstract

Pulmonary embolism (PE) represents a common disease in emergency medicine and guidelines for diagnosis and treatment have had wide diffusion. However, PE morbidity and mortality remain high, especially when associated to hemodynamic instability or right ventricular dysfunction. Prognostic stratification to identify high risk patients needing to receive more aggressive pharmacological and closer monitoring is of utmost importance. Modern guidelines for management of acute PE are based on risk stratification using either clinical, radiological, or laboratory findings. This article reviews the modern treatment of acute PE, which is customized upon patient prognosis. Accordingly the current risk stratification tools described in the literature such as clinical scores, echocardiography, helical computer tomography, and biomarkers will be reviewed.

Keywords: BNP; NT-proBNP; computer tomography; echocardiography; prognosis; pulmonary embolism; troponin.

Figure 1

Pathophysiology of hemodynamic instability due to PE and mechanism of biomarkers increase. Abbreviations: H-FABP, heart type fatty acid-binding proteins; LV, left ventricular; PE, pulmonary embolism; RV, right ventricular.

Figure 2

ESC criteria for identifing the risk of adverse prognosis in acute PE Abbreviations: BNP, brain natriuretic peptide; ESC, European Society of Cardiology; PF, pulmonary embolism; RVD, right ventricular dysfunction.

Figure 3

PE treatment according to modern guidelines. Abbreviations: BNP, brain natriuretic peptide; RHD, right heart dysfunction; IV, intravenous; SC, subcutaneous.

Figure 4

Pulmonary embolism severity index (P.E.S.I). Modified from Aujesky D, Perrier A, Roy PM, et al. Validation of a clinical prognostic model to identify low-risk patients with pulmonary embolism. J Intern Med. 2007;261:597–604. Abbreviations: COPD, chronic obstructive pulmonary disease; HR, heart rate; bpm, beats per minute; SBP, systolic blood pressure; RR, respiratory rate; BT, body temperature; SaO₂ arterial saturation of oxygen.

Figure 5

Clinical, instrumental and laboratory parameters associated with adverse outcomes in patients with acute Pe. Abbreviations: SBP, systolic blood pressure; ECG, echocardiogram; ESI, Pulmonary Embolism Severity Index; RVD, right ventricular dysfunction; CTPA, computer tomography pulmonary angiography; BNP, brain natriuretic peptides; HTFABP, heart type fatty acid binding protein; GFD-15, Growth differentiation factor-15; CTPE, computer tomography pulmonary embolism.