Professional Documents
Culture Documents
Pulmonary Embolism in
Orthopaedic Patients: Diagnosis
and Management
Abstract
Paul Tornetta, MD
Yelena Bogdan, MD
586
reliable, and many embolisms are silent. In a review of 695 patients, Kim
et al4 found a 27.8% rate of positive
CT results for PE in postoperative
orthopaedic patients. In that study, a
prior history of thromboembolic disease was the only significant predictor of a positive scan; a high body
mass index was a marginal predictor.
Thus, a combination of patient characteristics and symptoms may predict PE.
The magnitude of PE is a spectrum
ranging from central large clots to
tiny subsegmental clots. The clinical
relevance of this spectrum of condition is also quite varied. It is well
known that untreated emboli can
lead to death; however, many have
no clinical sequelae. How, then,
should management such as aggressive anticoagulation, which has its
own risks and costs, be chosen? As
methods of embolus detection become more sensitive for smaller occlusions, the clinical significance of
these small emboli is called into
Variable
Clinical signs and symptoms of DVT (ie, minimum leg swelling, pain
on palpation of deep
veins)
An alternative diagnosis
is less likely than PE
Heart rate >100 BPM
Immobilization or surgery
in previous 4 weeks
Previous DVT/PE
Hemoptysis
Malignancy (on treatment, treated in last 6
months, or palliative)
3
1.5
1.5
1.5
1
1
Table 2
Pulmonary Embolism Rates in a Validation Group of Patients Using the Wells Score Model and D-dimer
Pulmonary Embolism Rate (%)
Wells Score
<2
26
>6
Normal D-dimer
(95% CI)
Elevated D-dimer
(95% CI)
Overall
(95% CI)
2.7 (0.39)
2.9 (0.410)
20 (5.171.6)
0 (013.2)
37.3 (2550.9)
60 (32.383.7)
2 (0.27.1)
18.8 (12.426.6)
50 (27.272.8)
CI = confidence interval
Adapted with permission from Wells PS, Anderson DR, Rodger M, et al: Derivation of a simple clinical model to categorize patients probability
of pulmonary embolism: Increasing the models utility with the SimpliRED D-dimer. J Thromb Haemost 2000;83(3):416-420.
587
Figure 1
Clinically Relevant
Pulmonary Embolism
Line graph illustrating deaths from pulmonary embolism (PE), 1992 to 2006.
PEDeaths = number of deaths resulting from PE, TotPE = total number of
cases of PE. (Reproduced with permission from Burge AJ, Freeman KD,
Klapper PJ, Haramati LB: Increased diagnosis of pulmonary embolism
without a corresponding decline in mortality during the CT era. Clin Radiol
2008;63[4]:381-386.)
came more effective over time; however, better treatment modalities cannot also explain the increased PE
incidence. The other explanation is
that our PE tests are overly sensitive.
This would result in increased diagnosis of small emboli, which may
have fewer clinical sequelae. In other
words, the diagnosis exists but may
not be clinically significant. This
trend has been termed overdiagnosis
by Wiener et al.10
Several studies have focused on
overdiagnosis of PE. An analysis of
27 million patients over a 10-year
period (1994 to 2004) showed a
doubling of PE diagnoses without a
change in mortality rate,11 which
suggested a strong association of the
increased use of CT to explain these
changes (Figure 1). This trend leads
to the issue of appropriate selection
of patients for these imaging studies,
which are not without adverse effects
(eg, radiation exposure equivalent of
588
Figure 2
Axial CT pulmonary angiograms of the thorax demonstrating types of pulmonary embolism (PE). A, Right main central
PE (arrow). B, Segmental PE in right lower lobe (arrow). C, Subsegmental PE (arrow). D, Very small dot PE (arrow).
Note the progressive decrease in size from main to subsegmental and dot PEs, which may not be clinically relevant.
(Images courtesy of Akira Murakami, MD, Boston University Medical Center Radiology Department, Boston, MA.)
ripheral PE), and a higher rate of admission to the intensive care unit. Le
Gal et al17 also reported that subsegmental PE presented with less dyspnea and less chance of being characterized as having a high clinical
probability of PE.
Small emboli are being detected
with increased frequency, but this
589
Table 3
Characteristics of Patients With Pulmonary Embolus of Different Sizesa
Factor
Subsegmental (n = 22)
Segmental (n = 67)
Central (n = 245)
14 (63.6%)b
4 (18.2%)
14 (63.6%)
9 (40.9%)
15 (68.2%)
None
None
36 (53.7%)
16 (23.9%)
28 (41.8%)
41 (61.2%)
54 (80.6%)
None
3 (4.5%)
45 (18.4%)
117 (47.8%)
44 (18.0%)
177 (72.2%)
229 (93.5%)
6 (2.4%)
7 (2.9%)
Incidentally found
Dyspnea
Surgery or trauma
Coexisting DVT
Received anticoagulation
PE recurrence
PE-related death
590
Anticoagulation for
Pulmonary Embolism
It is clear that anticoagulation is of
paramount importance in treating
clinically relevant PE to prevent
death. In a landmark study, Barritt
and Jordan24 conducted a randomized controlled trial of patients with
PE. The group that received unfractionated heparin with vitamin K antagonist (n = 16) experienced no PE
recurrences or fatalities, whereas the
control group (n = 19) had 10 recurrences and 5 fatalities. Since then,
multiple studies have shown benefits
for anticoagulation and, based on
their results, societies have released
guidelines for anticoagulation therapy for PE.25,26 The American College of Chest Physicians provides the
following grade 1 (strong) recommendations: a confirmed PE is
treated with low-molecular-weight
heparin (LMWH), monitored intravenous or subcutaneous unfractionated heparin, weight-based subcutaneous unfractionated heparin, or
Table 4
Suggestions for Anticoagulation Therapy for Small Pulmonary Emboli23
Cardiopulmonary Reserve
Coexisting DVT
Other Factor(s)
Anticoagulate
No
No
No
Yes
Symptomatic
Asymptomatic/Incidental finding
Anticoagulation contraindicated
Recurrent PE
No
No
No
Yes
Yes
Yes
Adequate
Adequate
Adequate
Adequate
Adequate
Inadequate
Table 5
American College of Chest Physicians Recommendations for Treatment of Pulmonary Embolism25
Type of
Pulmonary
Embolism
Acute
Management
Goals of Management/
Rationale
tors
Evaluation for lifetime VKA
Incidence of recurrence higher at 2 yr
than provoked PE29
First unprovoked PE, no Lifetime VKA, target INR = 2.5
Grade of
Recommendationa
1C
1A
1A
1A
1C
1A
1A
1C
INR = international normalized ratio, LMWH = low-molecular-weight heparin, PE = pulmonary embolism, UFH = unfractionated heparin,
VKA = vitamin K antagonist
a
A = high-quality evidence, C = low-quality evidence
with a target international normalized ratio of 2.525 (Table 5). The British Thoracic Society has similar
guidelines, adding that thrombolytic
therapy should be used only in massive PE and that oral anticoagulation
should not be started unless PE is
confirmed with imaging. These
guidelines emphasize the risk of anticoagulation in certain patient sub-
591
Table 6
Summary of Outcomes of Anticoagulation Therapy for Pulmonary Embolism
Study
Nijkeuter et al35
Douketis et al36
Palla et al37
Patients
673 (PE)
2,052 (310 PE,
292 DVT + PE)
497 (PE)
Treatment Duration
(mo)
Follow-up (mo)
Recurrence Rate
3
6
3
54
2%
0.20.5/100 person-yearsa
12
12
9.6%
592
Summary
Orthopaedic patients present a dilemma for treating clinicians: they
are at high risk for both PE and
bleeding events. The orthopaedic
community has extensively debated
anticoagulation therapy for prophylaxis of PE, and the American Academy of Orthopaedic Surgeons has
presented clinical practice guidelines
to help guide care. However, data
suggest that we may be overdiagnosing PE, that not all pulmonary emboli are the same, that small emboli
are of questionable clinical relevance, and that the risks of anticoag-
593
6.
References printed in bold type indicate those published within the past
5 years.
1.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
7.
8.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 6,
21, 24, 36, 37, and 39 are level I
studies. References 3, 7, 12, 14, 1720, 22, 27, 32, 33, 35, 44, 45, and
47-49 are level II studies. References
4, 15, 16, and 34 are level III studies.
Reference 13 is a level IV study.
9.
10.
11.
12.
2.
13.
3.
14.
15.
4.
594
28.
29.
30.
31.
32.
33.
34.
36.
37.
38.
39.
40.
41.
42.
44.
45.
46.
47.
48.
49.
595