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Pulmonary embolism

Nature Reviews Disease Primers volume 4, Article number: 18028 (2018) Cite this article

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Abstract

Pulmonary embolism (PE) is caused by emboli, which have originated from venous thrombi, travelling to and occluding the arteries of the lung. PE is the most dangerous form of venous thromboembolism, and undiagnosed or untreated PE can be fatal. Acute PE is associated with right ventricular dysfunction, which can lead to arrhythmia, haemodynamic collapse and shock. Furthermore, individuals who survive PE can develop post-PE syndrome, which is characterized by chronic thrombotic remains in the pulmonary arteries, persistent right ventricular dysfunction, decreased quality of life and/or chronic functional limitations. Several important improvements have been made in the diagnostic and therapeutic management of acute PE in recent years, such as the introduction of a simplified diagnostic algorithm for suspected PE as well as phase III trials demonstrating the value of direct oral anticoagulants in acute and extended treatment of venous thromboembolism. Future research should aim to address novel treatment options (for example, fibrinolysis enhancers) and improved methods for predicting long-term complications and defining optimal anticoagulant therapy parameters in individual patients, and to gain a greater understanding of post-PE syndrome.

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Figure 1: Mechanisms of PE.
Figure 2: The sequence of RV failure in acute PE.
Figure 3: Validated diagnostic algorithms for suspected acute PE.
Figure 4: CTPA of a patient with acute and chronic signs of PE.
Figure 5: Radiological findings in a patient with CTEPH.
Figure 6: Pulmonary angiogram of a patient with inoperable CTEPH before and after BPA.

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Acknowledgements

The work of M.V.H. is supported by The Netherlands Organisation for Health Research and Development (ZonMW 848050006 and 848050007). The work of S.V.K., F.A.K. and S.B. is supported by the German Federal Ministry of Education and Research (BMBF 01EO1003 and 01EO1503). The work of F.A.K. is also supported by the Dutch Heart Foundation (2017T064).

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Authors and Affiliations

  1. Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands

    Menno V. Huisman, Suzanne C. Cannegieter, Pieter H. Reitsma & Frederikus A. Klok

  2. Center for Thrombosis and Hemostasis, University Hospital of the Johannes Gutenberg University Mainz, Mainz, Germany

    Stefano Barco, Stavros V. Konstantinides & Frederikus A. Klok

  3. Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece

    Stavros V. Konstantinides

  4. Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands

    Suzanne C. Cannegieter

  5. Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada

    Gregoire Le Gal & Marc Rodger

  6. Department of Pulmonary Medicine, VU Medical Center and Academic Medical Center, Amsterdam, Netherlands

    Anton Vonk Noordegraaf

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Contributions

Introduction (M.V.H. and F.A.K.); Epidemiology (S.C.C. and P.H.R.); Mechanisms/pathophysiology (A.V.N.); Diagnosis, screening and prevention (F.A.K., G.L.G. and M.R.); Management (M.V.H., S.V.K. and S.F.); Quality of life (F.A.K.); Outlook (M.V.H.); Overview of Primer (M.V.H.).

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Correspondence to Menno V. Huisman.

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Competing interests

M.V.H. has received research grants from Boehringer Ingelheim, Bayer HealthCare and PfizerBristol-Myers Squibb. He has received consultancy and lecture fees from PfizerBristol-Myers Squibb, Boehringer Ingelheim, Bayer HealthCare and Aspen. S.V.K. has received consultancy and lecture honoraria from Bayer HealthCare, Boehringer Ingelheim, Daiichi-Sankyo and PfizerBristol-Myers Squibb, payment for travel accommodation and meeting expenses from Bayer HealthCare and institutional grants from Boehringer Ingelheim, Bayer HealthCare and Daiichi-Sankyo. S.B. has received payment for travel accommodation and meeting expenses from Daiichi-Sankyo and Bayer HealthCare. F.A.K. has received research grants from Bayer HealthCare, Bristol-Myers Squibb, Boehringer Ingelheim, MSD and Actelion and non-financial research support from Daiichi-Sankyo. P.H.R. is a founder of VarmX BV, holds equity in this company and acts as chief scientific officer. P.H.R. is also an inventor on patents for factor V Leiden and prothrombin G20210A, and his department receives royalties related to these patents. G.L.G. holds an Early Researcher Award from the Province of Ontario, a Canadian Pacific Has Heart and Stroke Foundation Cardiovascular Award and the Chair in Diagnosis of Venous Thromboembolism, Department of Medicine, University of Ottawa Faculty of Medicine. M.R. holds a Chair in Venous Thrombosis and Thrombophilia, Department of Medicine, University of Ottawa Faculty of Medicine and a Heart and Stroke Foundation of Ontario Career Scientist Award. A.V.N. is supported by the Netherlands Organisation for Scientific Research (NOW) Vici grant and has received research grants from Actelion, Pfizer and United Therapeutics. All other authors declare no competing interests.

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Huisman, M., Barco, S., Cannegieter, S. et al. Pulmonary embolism. Nat Rev Dis Primers 4, 18028 (2018). https://doi.org/10.1038/nrdp.2018.28

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