Elsevier

The Lancet

Volume 379, Issue 9828, 12–18 May 2012, Pages 1835-1846
The Lancet

Seminar
Pulmonary embolism and deep vein thrombosis

https://doi.org/10.1016/S0140-6736(11)61904-1Get rights and content

Summary

Pulmonary embolism is the third most common cause of death from cardiovascular disease after heart attack and stroke. Sequelae occurring after venous thromboembolism include chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome. Venous thromboembolism and atherothrombosis share common risk factors and the common pathophysiological characteristics of inflammation, hypercoagulability, and endothelial injury. Clinical probability assessment helps to identify patients with low clinical probability for whom the diagnosis of venous thromboembolism can be excluded solely with a negative result from a plasma D-dimer test. The diagnosis is usually confirmed with compression ultrasound showing deep vein thrombosis or with chest CT showing pulmonary embolism. Most patients with venous thromboembolism will respond to anticoagulation, which is the foundation of treatment. Patients with pulmonary embolism should undergo risk stratification to establish whether they will benefit from the addition of advanced treatment, such as thrombolysis or embolectomy. Several novel oral anticoagulant drugs are in development. These drugs, which could replace vitamin K antagonists and heparins in many patients, are prescribed in fixed doses and do not need any coagulation monitoring in the laboratory. Although rigorous clinical trials have reported the effectiveness and safety of pharmacological prevention with low, fixed doses of anticoagulant drugs, prophylaxis remains underused in patients admitted to hospital at moderate risk and high risk for venous thromboembolism. In this Seminar, we discuss pulmonary embolism and deep vein thrombosis of the legs.

Introduction

Deep vein thrombosis and pulmonary embolism constitute venous thromboembolism. Deep vein thrombosis occurs most often in the legs, but can form in the veins of the arms,1 and in the mesenteric and cerebral veins. We focus on deep vein thrombosis of the legs and pulmonary embolism. Although these disorders are part of the same syndrome, important differences in epidemiology, diagnosis, and treatment exist between them.

Section snippets

Epidemiology

In population-based studies, no consensus exists about whether the incidence of venous thromboembolism varies according to sex. In a Norwegian study,2 the incidence of all first events of venous thromboembolism was 1·43 per 1000 person-years, and was slightly higher in women than in men. In a Swedish study,3 incidence was equal for both sexes. In a community-based study,4 incidence was higher for men than for women (1·14 per 1000 patient-years vs 1·05 per 1000 patient years). In the

Clinical probability assessment

Diagnosis of deep vein thrombosis and pulmonary embolism is dependent on several, mainly non-invasive, diagnostic techniques that should be used sequentially. Because use of a validated diagnostic work-up is associated with a substantially diminished risk of complications,27 implementation of such standardised approaches is highly recommended. Massive pulmonary embolism should be diagnosed quickly; its clinical features include shock or haemodynamic instability. Clinical probability assessment

Prognostic stratification of patients with pulmonary embolism

Patients with pulmonary embolism should be stratified according to prognosis.54 The Pulmonary Embolism Severity Index55 and its simplified version56 allow such stratification on a clinical basis (table 3). Several therapeutic implications exist for patients with pulmonary embolism: (1) high-risk patients (who represent about 5% of all symptomatic patients, with about a 15% short-term mortality) should be treated aggressively with thrombolytic drugs or surgical or catheter embolectomy;57 (2)

Prevention

Findings from rigorous clinical trials have shown the effectiveness and safety of pharmacological prevention with low, fixed doses of anticoagulant drugs (panel 2). For patients undergoing orthopaedic surgery—eg, total hip or knee replacement—novel oral anticoagulant drugs have been approved for thromboprophylaxis and are available instead of warfarin, heparins, and fondaparinux. Mechanical prophylactic measures, including graduated compression stockings and intermittent pneumatic compression

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