title: Novel management strategy for patients with suspected pulmonary embolism.
abstract: OBJECTIVE
  A simple management strategy is required for patients with acute pulmonary embolism which allows a rapid and reliable diagnosis in order to start timely and appropriate treatment.
  
  
  RESULTS
  Two hundred and four consecutive patients with suspected pulmonary embolism were managed according to a standardized protocol based on the clinical pretest probability and the initial haemodynamic presentation (shock index=heart rate divided by systolic blood pressure). Patients with a high pretest probability and a positive shock index (> or =1) (n=21) underwent urgent transthoracic echocardiography. Based on the presence or absence of right ventricular dysfunction, reperfusion treatment was initiated immediately. Patients with a negative shock index (<1) (n=183) underwent diagnostic evaluation including pretest probability, D-dimer, and spiral computed tomography (CT) as first-line tests. Echocardiography was performed only when a central pulmonary embolism was found in the spiral CT(n=33). According to our strategy, 98 patients met the diagnostic criteria of pulmonary embolism: 75 patients (all shock index <1) were treated with heparin alone, 16 (seven had a shock index > or =1) with thrombolysis, four (all shock index > or =1) with catheter fragmentation, and three (all shock index > or =1) with surgical embolectomy. The all-cause mortality rate at 30 days was 5%, and at 6 months 11%. Right ventricular dysfunction on baseline echocardiography was not associated with a higher mortality rate at 6 months (logrank 2.4, P=0.12).
  
  
  CONCLUSIONS
  The novel management strategy for patients with suspected pulmonary embolism resulted in a rapid diagnosis and treatment with a low 30-day mortality. In patients with pulmonary embolism and a positive shock index, time-consuming imaging tests can be avoided to reduce the risk of sudden death and not to delay reperfusion therapy.
authors.affiliation: Cardiology, Swiss Cardiovascular Center, University Hospital, CH-3010, Bern, Switzerland.
authors.forename: N
authors.initials: N
authors.lastname: Kucher
authors.forename: C M
authors.initials: CM
authors.lastname: Luder
authors.forename: T
authors.initials: T
authors.lastname: Dörnhöfer
authors.forename: S
authors.initials: S
authors.lastname: Windecker
authors.forename: B
authors.initials: B
authors.lastname: Meier
authors.forename: O M
authors.initials: OM
authors.lastname: Hess
mesh_terms: D000208:Acute Disease; D000284:Administration, Oral; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage; D004452:Echocardiography; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D006801:Humans; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000175:diagnosis / Q000628:therapy*; D015424:Reperfusion / Q000379:methods; D012770:Shock, Cardiogenic / Q000175:diagnosis / Q000628:therapy; D016019:Survival Analysis; D036542:Tomography, Spiral Computed / Q000379:methods; D016306:Vena Cava Filters
chemical_list: D000925:Anticoagulants; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D