Cor Vasa 2009, 51(11-12):767-772 | DOI: 10.33678/cor.2009.190

current treatment of patients with acute and subacute pulmonary embolism with respect to the newly published guidelines on the diagnosis and treatment of this disease

Aleš Král^1,*, Jan Bělohlávek¹, Vladimír Dytrych¹, Ondřej Šmíd¹, Štěpán Havránek¹, Jan Kaván², Jiří Widimský³, Aleš Linhart¹

¹ 2. interní klinika kardiologie a angiologie

² Radiodiagnostická klinika, Všeobecná fakultní nemocnice a 1. lékařská fakulta Univerzity Karlovy

³ Klinika kardiologie, Institut klinické a experimentální medicíny, Praha, Česká republika

Background: Risk stratification and the therapeutic decision process in patients with acute pulmonary embolism (PE) are complicated by lack of clinical data from large prospective randomized trials. The recently published Czech and European guidelines on the diagnosis and treatment of acute PE differ in the nomenclature and certain aspects of risk stratification.

Aims: The authors present a hypothetic comparison of both guidelines and the impact of their differences on risk stratification and resulting choice of therapy in a cohort of patients with acute and subacute PE from their institution.

Methods: The study was designed as a retrospective analysis of 209 consecutive patients hospitalized at our institution from January 2003 through October 2008 with verified symptomatic acute and subacute PE and treated according to then valid guidelines. PE was classified according to recent Czech (massive, submassive, small) and European (high-risk, intermediate-risk and low-risk) guidelines.

Results: According to Czech guidelines, PE was classified as massive in 45 patients (21.5%), as submassive in 93 patients (44.5%), and as small in 71 patients (34%). Accordingly, as per European guidelines, PE was classified as high-risk in 36 patients (17.2%), as intermediate-risk when taking into account the presence of right ventricular dysfunction (echocardiographically evaluated) and elevation of troponin I in 106 patients (51%), when considering also the level of BNP in 112 patients (53.6%). Depending on the evaluated biomarkers, PE was classified as low-risk in 67 and 61 patients, respectively (32 and 29.2%, respectively). The difference in the number of PE classified as massive vs. high-risk was determined by the fact that, in 9 patients, PE was classified as massive only because they presented with a syncope and were otherwise hemodynamically stable. No patient from this group died within 30 days. The difference in the number of other forms of PE was attributed to the fact that PE, classified as small in 10 patients, was reclassified as intermediate-risk because of an elevated level of cardiac biomarkers.

Conclusion: Our comparison of two current guidelines on the diagnosis and treatment of PE demonstrated that both guidelines differ in certain aspects of risk stratification and resulting choice of therapy. Our results suggest that syncope without persistent signs of hemo-dynamic instability might not necessarily be a marker of increased risk. Further analyses and prospective studies are justified to enable a more precise estimate of the individual risk in patients with PE.

Keywords: Acute pulmonary embolism; Risk stratification; Guidelines

Published: November 1, 2009  Show citation