title: [Pulmonary embolism].
abstract: Acute pulmonary embolism is an important differential diagnosis of acute chest pain. The clinical signs are often non-specific. However, diagnosis and therapy must be done quickly in order to reduce morbidity and mortality. The new (2014) European guidelines for acute pulmonary embolism (PE) focus on risk-adapted diagnostic algorithms and prognosis adapted therapy concepts. According to the hemodynamic presentation the division in a high-risk group (unstable patient with persistent hypotension or shock) or in non-high-risk groups (hemodynamically stable) was proposed. In the high-risk group the immediate diagnosis is usually done by multidetector spiral computed tomography (MDCT) and primarily the medical therapy of right ventricular dysfunction and thrombolysis is recommended.In the non-high-risk group, this is subdivided into an intermediate-risk group and low-risk group, the diagnosis algorithm based on the PE-pretest probability--determined by validated scores. Moreover, the diagnosis is usually secured by MDCT--the new gold standard in the PE-diagnosis, scores, or it can be primarily ruled out due to the high negative predictive value of D-dimer determination. To improve the prognostic risk stratification in non-high-risk group patients the additional detection of right ventricular dysfunction (MDCT, echocardiography), cardiac biomarkers (troponin, NT proBNP) and validated scores (e.g. Pulmonary Embolism Severity Index) is recommended. Therefore, the intermediate-risk group can be further subdivided. For treatment of non-high-risk group patients, the initial anticoagulation (except those with severe renal insufficiency) using low molecular weight heparin/fondaparinux and conversion to vitamin-K antagonists or alternatively with direct oral anticoagulants (DOAK) is recommended. Hemodynamically stable patients with right ventricular dysfunction and myocardial ischemia (Intermediate-high-risk group patients) but with clinically progressive hemodynamic decompensation may benefit from systemic thrombolysis as well. Due to the high risk of bleeding in the PEITHO study, however, a critical individual risk-benefit evaluation should be done. A dose reduced systemic or local ultrasound-assisted thrombolysis could gain importance in the future. For very selected patients in the low-risk group early outpatient treatment could be considered.The diagnosis and treatment of pulmonary embolism remains complex. Improved algorithms support the diagnosis procedures and therapy decisions. Direct oral anticoagulants are a new first-line therapy alternative for hemodynamically stable non-high-risk patients.
authors.affiliation: Universitätsklinikum Hamburg-Eppendorf.
authors.forename: Gerold
authors.initials: G
authors.lastname: Söffker
authors.affiliation: Universitätsklinikum Hamburg-Eppendorf.
authors.forename: Stefan
authors.initials: S
authors.lastname: Kluge
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D002637:Chest Pain / Q000175:diagnosis* / Q000209:etiology / Q000517:prevention & control; D003937:Diagnosis, Differential; D004452:Echocardiography / Q000379:methods*; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D011655:Pulmonary Embolism / Q000150:complications / Q000175:diagnosis* / Q000628:therapy*; D014057:Tomography, X-Ray Computed / Q000379:methods*
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents