Listening Smarter: AI-Powered Stethoscope Transforms Heart Valve Disease Screening
February 11, 2026
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Background
Pulmonary embolism (PE) is one of the most frequent and severe diseases; a significant number of patients die within the initial hours of the disease. Even though diagnostic technologies have improved, the delays in diagnosing PE have remained an issue of concern. It is the third most frequent cause of cardiovascular mortality after coronary artery disease and stroke and the leading cause of death in cancer patients. Furthermore, it is well established that PE is the leading cause of death among pregnant and postpartum women.
Early identification and management of the condition can help avoid recurrent pulmonary embolism and mortality rate among patients who survive PE. However, the signs and symptoms may be very mild and are therefore easily overlooked, especially in a condition like PE. If left untreated, about one-third of patients who might survive the first episode are prone to die from other embolic episodes.
Pulmonary embolisms are further categorized as acute and chronic upon diagnosis. In an acute embolism, the embolus occupies the center of the lumen of a vessel or obstructs a vessel and may lead to distention of the vessel. On the other hand, chronic embolism is eccentrically located, narrows the arterial diameter by more than 50 percent and demonstrates thrombus recanalization; such an embolism may be associated with an arterial web.
Epidemiology
In the U. S., pulmonary embolism (PE) affects one in 1,000 people per year, and the increased utilization of CT scans since 2008 has resulted in more reported cases. The death rate of PE has coming down from 1979 to 1998 and it reveals that the death rate of this disease has been decreasing in the past several years. PE is related with DVT in 60-80% of patients and is usually asymptomatic and is the third leading cause of hospital- deaths with the overall estimate of 650,000 cases per year in the USA.
Venous thromboembolism may occur to approximately one individual in every 1,000 people every year and nearly 250,000 new cases occur in the United States annually.
Globally, the prevalence rate of PE also differs due to the inconsistency in diagnosing the condition.
It is revealed that the risk of PE in men is higher as compared to women causing 20 to 30 % higher mortality rates. VTE is more prevalent among male patients above 60 years of age, whereas PE is more common in female patients below 55 years of age. Black patients have higher PE incidence and mortality than white patients.
Anatomy
Pathophysiology
Pulmonary embolism (PE) can be defined as a condition that impacts on both the respiratory and the circulatory systems.
Respiratory Effects
PE leads to several acute respiratory issues, such as:
Increased alveolar dead space
Hypoxemia (low blood oxygen)
Hyperventilation
Other potential consequences include surfactant loss in certain regions, as well as pulmonary infarction. There are therefore four major causes of hypoxemia in patients with PE namely: V/Q mismatch, intrapulmonary shunt, reduction in the cardiac output, and an intracardiac shunt due to patent foramen ovale. Although pulmonary infarction is not common because of the anastomosis of bronchial arterial circulation.
Hemodynamic Effects
PE causes constriction of the pulmonary vasculature and decreases the cross-sectional area, thus increases pulmonary vascular resistance and RV afterload. This may result in right ventricular failure whenever the afterload reaches its maximum limit. Hormonal and reflex mechanisms also play a part in the constriction of pulmonary arteries. After anticoagulant therapy, the resolution of the emboli occurs within the first two weeks, however, some particles may remain embedded for as long as months to years, this may lead to chronic pulmonary hypertension if the embolus never dissolves or if recurrent emboli occur.
Etiology
Venous Thromboembolism (VTE)
Deep Vein Thrombosis (DVT): About 90% of PE is caused by leg or pelvic vein blood clots that travel to the lungs.
Hypercoagulable States
Inherited Conditions: There are hereditary factors in clotting which include Factor V Leiden, prothrombin gene mutation as well as Protein C, Protein S, and Antithrombin deficiency.
Acquired Conditions: Risk of clot formation increases in conditions including but not limited to cancer, pregnancy, obesity, or when a person must stay immobile for long hours such as during flights, bed rest etc.
Surgery and Trauma
Major surgeries can result in the formation of venous clots because of immobility and due to the injuries on the blood vessels especially when the surgery involves operations such as the hip or knee operations.
Prolonged Immobility
Constant sitting or bed rest, for instance through hospitalization or an extensive journey result to what is referred to as oedema thus promoting clot formation.
Cancer
Some types of cancer such as the lung cancer or pancreatic and ovarian cancer and certain treatments like chemotherapy causes increase in clotting chances.
Hormonal Factors
Pregnancy and Postpartum Period: This is so due to hormonal changes experienced by pregnant women and must necessarily lead a relatively sedentary lifestyle due to their pregnancy.
Hormone Replacement Therapy (HRT) or Oral Contraceptives: Estrogen promotes hypercoagulable state, in other words influences the tendency to form blood clots.
Genetics
Prognostic Factors
The prognosis of pulmonary embolism (PE) varies with the state of health of the affected patient and the kind of management that the patient undergoes. Around 25 % of people with PE are prone to die suddenly. Mortality is subdivided into high risk and low or moderate risk. The use of anticoagulant therapy decreases the mortality rate to a level of below 5 percent with lung abnormities resolving in most persons after three months. If left untreated, PE has a 30% chance of being fatal.
A survey revealed that mortality of PE patients was 24% within one year and the main causes were heart failure, another PE, infection or cancer. Some biomarkers including natriuretic peptides and plasma lactate are associated with increased mortality. The mortality of HI-PE is 65%, intermediate risk is 5 to 25% and low risk has a 1% mortality.
Clinical History
Age Group
PE can occur at any age but is most prevalent in persons of 60 years and above. It is age related and the incidence rises with age. Children represent only a small proportion of reported infections but its association with the use of central venous catheter.
Physical Examination
In pulmonary embolism (PE), physical examination may show tachycardia, tachypnea, hypoxemia, or signs of deep vein thrombosis. Respiratory changes observed might be Increased work of breathing, poor breath sounds or crackles. Some of the cardiovascular findings may be presence of jugular venous pulsation, right ventricular impulse, or increased intensity of the second heart sound. In severe conditions there may be cyanosis, cold and sweaty skin, DVT signs which include leg swelling and tenderness usually in the calf, extreme cold/blue toe syndrome. In some instances, the physical signs may be minimal or absent especially when the emboli are small.
Age group
Associated comorbidity
Deep Vein Thrombosis (DVT): Deep vein thrombosis is closely related to PE as clots from the deep veins in the legs or pelvis can travel to the lungs.
Cancer: Patients with active cancer or receiving chemotherapy suddenly have increased coagulation, so they have a higher risk level.
Surgery or Trauma: Those patients with massive lower limb surgery such as the orthopedic or the abdominal ones, or the patients with major trauma are especially at risk owing to the immobility and the potential clot formation.
Pregnancy and Postpartum: Pregnancy brings hormonal changes and decreased mobility, and the risk is even higher in the postpartum period.
Associated activity
Acuity of presentation
Acute presentation: This condition usually develops acutely and is potentially fatal if left untreated. Symptoms include:
Dyspnea is another related symptom which has sudden onset of shortness of breath.
Pleuritic Chest Pain: Sudden, stabbing pain with worsening on breathing.
Tachycardia: Cough, sometimes with hemoptysis
Syncope or Near-Syncope: May be seen in massive PE due to hemodynamic instability of the patient.
Subacute Presentation: Some patients may have slow presentation of the symptoms which may depend on the size, number or recurrence of the PEs which includes;
Low level of shortness of breath, tiredness, or feeling generally unwell for days to weeks.
Chronic Presentation: In some cases, PE can evolve into CTEPH with gradual development of exertional dyspnea, fatigue, and manifestations of right heart failure.
Differential Diagnoses
Angina Pectoris
Aortic Stenosis
Cardiogenic Shock
Dilated Cardiomyopathy
Acute Respiratory Distress Syndrome (ARDS)
Anxiety Disorders
Atrial Fibrillation
Cor Pulmonale
Fat Embolism
Hypersensitivity Pneumonitis
Myocardial Infarction
Emphysema
Mitral Stenosis
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Initial Management
Surgical or Interventional Therapies:
Embolectomy: This is a surgical procedure where the blood clot is physically removed from the affected blood vessel, it is only conducted on patients with severe conditions where the use of thrombolytics cannot be done or have not worked as planned.
Catheter-Directed Thrombolysis: Technique whereby thrombolytics are directly infused through a catheter to the site of the clot in specific cases, massive PE.
Supportive Care:
Pain Management: Try to manage some amount of pain and discomfort, sometimes it even can be reduced with help of analgesics. Daily checks of general health, oxygen saturation and tolerance of treatment.
by Stage
by Modality
Chemotherapy
Radiation Therapy
Surgical Interventions
Hormone Therapy
Immunotherapy
Hyperthermia
Photodynamic Therapy
Stem Cell Transplant
Targeted Therapy
Palliative Care
use-of-a-non-pharmacological-approach-for-treating-pulmonary-embolism
Supportive Care: Supports for supplemental oxygen requirement to safeguard the adequate oxygen saturation levels and put off respiratory discomfort. However, in patients with severe hypoxemia or respiratory failure, the therapy may call for the use of a mechanical ventilator to assist in breathing.
Lifestyle and Preventive Measures: Promoting mobility and physical exercise in hospitalised patients especially of patients who have high risk of developing VTE minimises formation of new clots. To increase venous return and minimise the occurrence of DVT which causes PE, patients should be encouraged to wear intermittent pneumatic compression devices or graduated compression stockings.
Role of Anticoagulants
Enoxaparin (Lovenox): Enoxaparin is the first low molecular heparin with LMWH approved in the U. S., and this medication is applied to treat and prevent the development of deep vein thrombosis or pulmonary embolism. It achieves this by increasing the inhibitory effects of factor Xa and thrombin with the primary focus on factor Xa. It is utilised in pregnant women, but it is not clearly known which of the two; unfractionated heparin or low molecular weight heparin is safer. There is no need for monitoring PT or aPTT in patients receiving fondaparinux unlike conventional heparin, but factor Xa levels may be tested if required.
Dalteparin: It is another LMWH which is like enoxaparin but is used particularly for the prevention of DVT in patients who are undergoing abdominal surgery. It has a different dosing regimen but is also not dependent on routine PT or aPTT monitoring. Some patients may require the determination of Factor Xa levels especially if there is a doubt about the proper dosage.
Tinzaparin: It is an LMWH prescribed for the management of DVT in hospitalised patients. It boosts the action of antithrombin III through which it helps to inhibit factor Xa and thrombin effectively though it focuses on factor Xa inhibition.
Heparin: It increases the activity of antithrombin III to prevent conversion of fibrinogen to fibrin in a bid to check clot formation. It does not only bring dissolving of clots that are formed but it prevents the formation of new blood clots. For Unfractionated heparin (UFH) an assessment of aPTT should be done 6 hours after the first administration of the drug to check for appropriateness of dosage.
Warfarin: It inhibits the synthesis of vitamin K-dependent clotting factors hence used in the prevention and treatment of venous thromboembolism. It should only be initiated when the blood is adequately anticoagulated with heparin because of increased risk of clot propagation or recurrence.
Fondaparinux Sodium: It is a synthetic anticoagulant which has this mechanism of action among the factors of blood coagulation, it selectively targets factor Xa. It has good biological availability, a long-term clearance half live and gives long term anticoagulant effect. It does not have any influence on the prothrombin time interval and aPTT times as well as platelet function.
Role of Thrombolytics
Reteplase: It is second generation recombinant tissue plasminogen activator (tPA) which acts by activating plasminogen to plasmin and thereby helping in breakdown of clots. It is like alteplase for the opening of TIMI 2 or 3 at 90 minutes and can be administered as the single or the double bolus. It is faster and probably more effective in large or old thrombi due to it lower binding affinity for fibrin which allow better penetration into the clot. It is not approved by the FDA for use in pulmonary embolism, but it has been used off label especially where coronary dosing is applicable.
Alteplase: It is a recombinant tPA that it applied for acute myocardial infarction, ischemic stroke, and pulmonary embolism. In the emergency department, the medication is usually given through an infusion that takes 90-120 minutes for treatment of pulmonary embolism. The most common is a shortened 90-minute protocol that is considered even safer and more efficient. Because of such effects heparin therapy is normally given or continued after the infusion once the clotting tests go up to normal.
Role of Direct Thrombin Inhibitors and Factor Xa Inhibitors
Rivaroxaban: This drug is used for managing pulmonary embolism and for prevention of recurrent episodic after radical anticoagulation therapy for the first 6 months. It is also indicated for various venous thromboembolism (VTE) conditions, including:
Strategies for decreasing stroke and systemic embolism in nonvalvular atrial fibrillation. Therapeutic management of deep vein thrombosis (DVT)
Being an expert, it is your responsibility to ensure the patient does not have a repeat of DVT and PE. Prevention of DVT after joint arthroplasty for hip and knee ailments. Reducing the risk of VTE in the acutely ill medical patients with acceptable immobility (and low bleeding risk). Preventing death or myocardial infarction, revascularization, or amputation in coronary or peripheral artery disease
Apixaban: The above is recommended for the treatment of PE and can also be used in the prevention of the recurrence of this disease after 6 months of medication
Dabigatran: It is utilised for the management of DVT and PE in patients who have been given a parenteral anticoagulant for 5-10 days. It is also useful in prevention of recurrent DVT, and PE among patients who have previously undergone the treatment.
Edoxaban: It is a factor Xa inhibitor which is used for the Treatment of DVT and PE in patients who have undergone initial INR parenteral anticoagulation for 5-10 days.
Betrixaban: They are effective in the prevention of VTE in the hospitalized adult, with an acute medical illness and has moderate to severe immobility and other VTE risk factors.
use-of-intervention-with-a-procedure-in-treating-pulmonary-embolism
Thrombectomy: This procedure is done through the process of mechanical embolectomy where the blood clot is physically and surgically removed from the pulmonary arteries. It is mostly used for patients with massive PE or those who are not suitable candidates for thrombolytics. Thrombectomy can be done through using catheters (PTA or percutaneous thrombectomy) or through surgery.
Thrombolysis: Popularly called clot-busting therapy, this involves the delivery of thrombolytic agents to the clot to dissolve it. This approach is only applicable for patients with high risk or massive PE to achieve rapid clot resolution. The commonly used thrombolytic agents are alteplase (recombinant tissue plasminogen activator RT-PA) and reteplase. Fibrinolysis can be used in two ways, through systemic thrombolysis or through catheter directed thrombolysis.
Inferior Vena Cava (IVC) Filter Placement: An IVC filter is a filter placed within the inferior vena cava to catch blood clots and stop it from moving from the legs to the lungs. They are used in patients for whom anticoagulation therapy is contraindicated or in patients with recurrent embolism while on anticoagulation. The filter is normally deployed using a catheter deployed through the femoral or subclavian vein.
Surgical Embolectomy: This generally invasive method involves the surgical endovascular removal of the embolus from the pulmonary arteries. It is used in the management of massive PE when other forms of intervention cannot be performed or have proven ineffective. This operation is typically done in the operating theatre under general anesthesia.
use-of-phases-in-managing-pulmonary-embolism
Acute Phase: The initial management entails the identification and control of factors that may worsen the condition of the patient. This frequently involves the use of anticoagulants which may include heparin, low molecular weight heparin (LMWH) for managing the acute event. In severe forms thrombolytic therapy or thrombectomy should be carried out for the faster dissolving of the blood clots.
Subacute Phase: The long-term management of patients involves the prescription of specific medications such as warfarin, rivaroxaban or apixaban to reduce the risk of such events in the future. Maintenance of therapeutic levels is also part of this phase to include consistent follow-ups for the same.
Chronic Phase: For long term management, patients may require continued use of anticoagulants, changes to their eating habits and the treatment of other associated risk factors. Common symptoms include dyspnoea, cough, chest pain, haemoptysis and tachycardia but one-third of patients may remain asymptomatic at presentation.
Medication
Future Trends
Pulmonary embolism (PE) is one of the most frequent and severe diseases; a significant number of patients die within the initial hours of the disease. Even though diagnostic technologies have improved, the delays in diagnosing PE have remained an issue of concern. It is the third most frequent cause of cardiovascular mortality after coronary artery disease and stroke and the leading cause of death in cancer patients. Furthermore, it is well established that PE is the leading cause of death among pregnant and postpartum women.
Early identification and management of the condition can help avoid recurrent pulmonary embolism and mortality rate among patients who survive PE. However, the signs and symptoms may be very mild and are therefore easily overlooked, especially in a condition like PE. If left untreated, about one-third of patients who might survive the first episode are prone to die from other embolic episodes.
Pulmonary embolisms are further categorized as acute and chronic upon diagnosis. In an acute embolism, the embolus occupies the center of the lumen of a vessel or obstructs a vessel and may lead to distention of the vessel. On the other hand, chronic embolism is eccentrically located, narrows the arterial diameter by more than 50 percent and demonstrates thrombus recanalization; such an embolism may be associated with an arterial web.
In the U. S., pulmonary embolism (PE) affects one in 1,000 people per year, and the increased utilization of CT scans since 2008 has resulted in more reported cases. The death rate of PE has coming down from 1979 to 1998 and it reveals that the death rate of this disease has been decreasing in the past several years. PE is related with DVT in 60-80% of patients and is usually asymptomatic and is the third leading cause of hospital- deaths with the overall estimate of 650,000 cases per year in the USA.
Venous thromboembolism may occur to approximately one individual in every 1,000 people every year and nearly 250,000 new cases occur in the United States annually.
Globally, the prevalence rate of PE also differs due to the inconsistency in diagnosing the condition.
It is revealed that the risk of PE in men is higher as compared to women causing 20 to 30 % higher mortality rates. VTE is more prevalent among male patients above 60 years of age, whereas PE is more common in female patients below 55 years of age. Black patients have higher PE incidence and mortality than white patients.
Pulmonary embolism (PE) can be defined as a condition that impacts on both the respiratory and the circulatory systems.
Respiratory Effects
PE leads to several acute respiratory issues, such as:
Increased alveolar dead space
Hypoxemia (low blood oxygen)
Hyperventilation
Other potential consequences include surfactant loss in certain regions, as well as pulmonary infarction. There are therefore four major causes of hypoxemia in patients with PE namely: V/Q mismatch, intrapulmonary shunt, reduction in the cardiac output, and an intracardiac shunt due to patent foramen ovale. Although pulmonary infarction is not common because of the anastomosis of bronchial arterial circulation.
Hemodynamic Effects
PE causes constriction of the pulmonary vasculature and decreases the cross-sectional area, thus increases pulmonary vascular resistance and RV afterload. This may result in right ventricular failure whenever the afterload reaches its maximum limit. Hormonal and reflex mechanisms also play a part in the constriction of pulmonary arteries. After anticoagulant therapy, the resolution of the emboli occurs within the first two weeks, however, some particles may remain embedded for as long as months to years, this may lead to chronic pulmonary hypertension if the embolus never dissolves or if recurrent emboli occur.
Venous Thromboembolism (VTE)
Deep Vein Thrombosis (DVT): About 90% of PE is caused by leg or pelvic vein blood clots that travel to the lungs.
Hypercoagulable States
Inherited Conditions: There are hereditary factors in clotting which include Factor V Leiden, prothrombin gene mutation as well as Protein C, Protein S, and Antithrombin deficiency.
Acquired Conditions: Risk of clot formation increases in conditions including but not limited to cancer, pregnancy, obesity, or when a person must stay immobile for long hours such as during flights, bed rest etc.
Surgery and Trauma
Major surgeries can result in the formation of venous clots because of immobility and due to the injuries on the blood vessels especially when the surgery involves operations such as the hip or knee operations.
Prolonged Immobility
Constant sitting or bed rest, for instance through hospitalization or an extensive journey result to what is referred to as oedema thus promoting clot formation.
Cancer
Some types of cancer such as the lung cancer or pancreatic and ovarian cancer and certain treatments like chemotherapy causes increase in clotting chances.
Hormonal Factors
Pregnancy and Postpartum Period: This is so due to hormonal changes experienced by pregnant women and must necessarily lead a relatively sedentary lifestyle due to their pregnancy.
Hormone Replacement Therapy (HRT) or Oral Contraceptives: Estrogen promotes hypercoagulable state, in other words influences the tendency to form blood clots.
The prognosis of pulmonary embolism (PE) varies with the state of health of the affected patient and the kind of management that the patient undergoes. Around 25 % of people with PE are prone to die suddenly. Mortality is subdivided into high risk and low or moderate risk. The use of anticoagulant therapy decreases the mortality rate to a level of below 5 percent with lung abnormities resolving in most persons after three months. If left untreated, PE has a 30% chance of being fatal.
A survey revealed that mortality of PE patients was 24% within one year and the main causes were heart failure, another PE, infection or cancer. Some biomarkers including natriuretic peptides and plasma lactate are associated with increased mortality. The mortality of HI-PE is 65%, intermediate risk is 5 to 25% and low risk has a 1% mortality.
Age Group
PE can occur at any age but is most prevalent in persons of 60 years and above. It is age related and the incidence rises with age. Children represent only a small proportion of reported infections but its association with the use of central venous catheter.
In pulmonary embolism (PE), physical examination may show tachycardia, tachypnea, hypoxemia, or signs of deep vein thrombosis. Respiratory changes observed might be Increased work of breathing, poor breath sounds or crackles. Some of the cardiovascular findings may be presence of jugular venous pulsation, right ventricular impulse, or increased intensity of the second heart sound. In severe conditions there may be cyanosis, cold and sweaty skin, DVT signs which include leg swelling and tenderness usually in the calf, extreme cold/blue toe syndrome. In some instances, the physical signs may be minimal or absent especially when the emboli are small.
Deep Vein Thrombosis (DVT): Deep vein thrombosis is closely related to PE as clots from the deep veins in the legs or pelvis can travel to the lungs.
Cancer: Patients with active cancer or receiving chemotherapy suddenly have increased coagulation, so they have a higher risk level.
Surgery or Trauma: Those patients with massive lower limb surgery such as the orthopedic or the abdominal ones, or the patients with major trauma are especially at risk owing to the immobility and the potential clot formation.
Pregnancy and Postpartum: Pregnancy brings hormonal changes and decreased mobility, and the risk is even higher in the postpartum period.
Acute presentation: This condition usually develops acutely and is potentially fatal if left untreated. Symptoms include:
Dyspnea is another related symptom which has sudden onset of shortness of breath.
Pleuritic Chest Pain: Sudden, stabbing pain with worsening on breathing.
Tachycardia: Cough, sometimes with hemoptysis
Syncope or Near-Syncope: May be seen in massive PE due to hemodynamic instability of the patient.
Subacute Presentation: Some patients may have slow presentation of the symptoms which may depend on the size, number or recurrence of the PEs which includes;
Low level of shortness of breath, tiredness, or feeling generally unwell for days to weeks.
Chronic Presentation: In some cases, PE can evolve into CTEPH with gradual development of exertional dyspnea, fatigue, and manifestations of right heart failure.
Angina Pectoris
Aortic Stenosis
Cardiogenic Shock
Dilated Cardiomyopathy
Acute Respiratory Distress Syndrome (ARDS)
Anxiety Disorders
Atrial Fibrillation
Cor Pulmonale
Fat Embolism
Hypersensitivity Pneumonitis
Myocardial Infarction
Emphysema
Mitral Stenosis
Initial Management
Surgical or Interventional Therapies:
Embolectomy: This is a surgical procedure where the blood clot is physically removed from the affected blood vessel, it is only conducted on patients with severe conditions where the use of thrombolytics cannot be done or have not worked as planned.
Catheter-Directed Thrombolysis: Technique whereby thrombolytics are directly infused through a catheter to the site of the clot in specific cases, massive PE.
Supportive Care:
Pain Management: Try to manage some amount of pain and discomfort, sometimes it even can be reduced with help of analgesics. Daily checks of general health, oxygen saturation and tolerance of treatment.
Pulmonary Medicine
Supportive Care: Supports for supplemental oxygen requirement to safeguard the adequate oxygen saturation levels and put off respiratory discomfort. However, in patients with severe hypoxemia or respiratory failure, the therapy may call for the use of a mechanical ventilator to assist in breathing.
Lifestyle and Preventive Measures: Promoting mobility and physical exercise in hospitalised patients especially of patients who have high risk of developing VTE minimises formation of new clots. To increase venous return and minimise the occurrence of DVT which causes PE, patients should be encouraged to wear intermittent pneumatic compression devices or graduated compression stockings.
Pulmonary Medicine
Enoxaparin (Lovenox): Enoxaparin is the first low molecular heparin with LMWH approved in the U. S., and this medication is applied to treat and prevent the development of deep vein thrombosis or pulmonary embolism. It achieves this by increasing the inhibitory effects of factor Xa and thrombin with the primary focus on factor Xa. It is utilised in pregnant women, but it is not clearly known which of the two; unfractionated heparin or low molecular weight heparin is safer. There is no need for monitoring PT or aPTT in patients receiving fondaparinux unlike conventional heparin, but factor Xa levels may be tested if required.
Dalteparin: It is another LMWH which is like enoxaparin but is used particularly for the prevention of DVT in patients who are undergoing abdominal surgery. It has a different dosing regimen but is also not dependent on routine PT or aPTT monitoring. Some patients may require the determination of Factor Xa levels especially if there is a doubt about the proper dosage.
Tinzaparin: It is an LMWH prescribed for the management of DVT in hospitalised patients. It boosts the action of antithrombin III through which it helps to inhibit factor Xa and thrombin effectively though it focuses on factor Xa inhibition.
Heparin: It increases the activity of antithrombin III to prevent conversion of fibrinogen to fibrin in a bid to check clot formation. It does not only bring dissolving of clots that are formed but it prevents the formation of new blood clots. For Unfractionated heparin (UFH) an assessment of aPTT should be done 6 hours after the first administration of the drug to check for appropriateness of dosage.
Warfarin: It inhibits the synthesis of vitamin K-dependent clotting factors hence used in the prevention and treatment of venous thromboembolism. It should only be initiated when the blood is adequately anticoagulated with heparin because of increased risk of clot propagation or recurrence.
Fondaparinux Sodium: It is a synthetic anticoagulant which has this mechanism of action among the factors of blood coagulation, it selectively targets factor Xa. It has good biological availability, a long-term clearance half live and gives long term anticoagulant effect. It does not have any influence on the prothrombin time interval and aPTT times as well as platelet function.
Pulmonary Medicine
Reteplase: It is second generation recombinant tissue plasminogen activator (tPA) which acts by activating plasminogen to plasmin and thereby helping in breakdown of clots. It is like alteplase for the opening of TIMI 2 or 3 at 90 minutes and can be administered as the single or the double bolus. It is faster and probably more effective in large or old thrombi due to it lower binding affinity for fibrin which allow better penetration into the clot. It is not approved by the FDA for use in pulmonary embolism, but it has been used off label especially where coronary dosing is applicable.
Alteplase: It is a recombinant tPA that it applied for acute myocardial infarction, ischemic stroke, and pulmonary embolism. In the emergency department, the medication is usually given through an infusion that takes 90-120 minutes for treatment of pulmonary embolism. The most common is a shortened 90-minute protocol that is considered even safer and more efficient. Because of such effects heparin therapy is normally given or continued after the infusion once the clotting tests go up to normal.
Pulmonary Medicine
Rivaroxaban: This drug is used for managing pulmonary embolism and for prevention of recurrent episodic after radical anticoagulation therapy for the first 6 months. It is also indicated for various venous thromboembolism (VTE) conditions, including:
Strategies for decreasing stroke and systemic embolism in nonvalvular atrial fibrillation. Therapeutic management of deep vein thrombosis (DVT)
Being an expert, it is your responsibility to ensure the patient does not have a repeat of DVT and PE. Prevention of DVT after joint arthroplasty for hip and knee ailments. Reducing the risk of VTE in the acutely ill medical patients with acceptable immobility (and low bleeding risk). Preventing death or myocardial infarction, revascularization, or amputation in coronary or peripheral artery disease
Apixaban: The above is recommended for the treatment of PE and can also be used in the prevention of the recurrence of this disease after 6 months of medication
Dabigatran: It is utilised for the management of DVT and PE in patients who have been given a parenteral anticoagulant for 5-10 days. It is also useful in prevention of recurrent DVT, and PE among patients who have previously undergone the treatment.
Edoxaban: It is a factor Xa inhibitor which is used for the Treatment of DVT and PE in patients who have undergone initial INR parenteral anticoagulation for 5-10 days.
Betrixaban: They are effective in the prevention of VTE in the hospitalized adult, with an acute medical illness and has moderate to severe immobility and other VTE risk factors.
Pulmonary Medicine
Thrombectomy: This procedure is done through the process of mechanical embolectomy where the blood clot is physically and surgically removed from the pulmonary arteries. It is mostly used for patients with massive PE or those who are not suitable candidates for thrombolytics. Thrombectomy can be done through using catheters (PTA or percutaneous thrombectomy) or through surgery.
Thrombolysis: Popularly called clot-busting therapy, this involves the delivery of thrombolytic agents to the clot to dissolve it. This approach is only applicable for patients with high risk or massive PE to achieve rapid clot resolution. The commonly used thrombolytic agents are alteplase (recombinant tissue plasminogen activator RT-PA) and reteplase. Fibrinolysis can be used in two ways, through systemic thrombolysis or through catheter directed thrombolysis.
Inferior Vena Cava (IVC) Filter Placement: An IVC filter is a filter placed within the inferior vena cava to catch blood clots and stop it from moving from the legs to the lungs. They are used in patients for whom anticoagulation therapy is contraindicated or in patients with recurrent embolism while on anticoagulation. The filter is normally deployed using a catheter deployed through the femoral or subclavian vein.
Surgical Embolectomy: This generally invasive method involves the surgical endovascular removal of the embolus from the pulmonary arteries. It is used in the management of massive PE when other forms of intervention cannot be performed or have proven ineffective. This operation is typically done in the operating theatre under general anesthesia.
Pulmonary Medicine
Acute Phase: The initial management entails the identification and control of factors that may worsen the condition of the patient. This frequently involves the use of anticoagulants which may include heparin, low molecular weight heparin (LMWH) for managing the acute event. In severe forms thrombolytic therapy or thrombectomy should be carried out for the faster dissolving of the blood clots.
Subacute Phase: The long-term management of patients involves the prescription of specific medications such as warfarin, rivaroxaban or apixaban to reduce the risk of such events in the future. Maintenance of therapeutic levels is also part of this phase to include consistent follow-ups for the same.
Chronic Phase: For long term management, patients may require continued use of anticoagulants, changes to their eating habits and the treatment of other associated risk factors. Common symptoms include dyspnoea, cough, chest pain, haemoptysis and tachycardia but one-third of patients may remain asymptomatic at presentation.
Pulmonary embolism (PE) is one of the most frequent and severe diseases; a significant number of patients die within the initial hours of the disease. Even though diagnostic technologies have improved, the delays in diagnosing PE have remained an issue of concern. It is the third most frequent cause of cardiovascular mortality after coronary artery disease and stroke and the leading cause of death in cancer patients. Furthermore, it is well established that PE is the leading cause of death among pregnant and postpartum women.
Early identification and management of the condition can help avoid recurrent pulmonary embolism and mortality rate among patients who survive PE. However, the signs and symptoms may be very mild and are therefore easily overlooked, especially in a condition like PE. If left untreated, about one-third of patients who might survive the first episode are prone to die from other embolic episodes.
Pulmonary embolisms are further categorized as acute and chronic upon diagnosis. In an acute embolism, the embolus occupies the center of the lumen of a vessel or obstructs a vessel and may lead to distention of the vessel. On the other hand, chronic embolism is eccentrically located, narrows the arterial diameter by more than 50 percent and demonstrates thrombus recanalization; such an embolism may be associated with an arterial web.
In the U. S., pulmonary embolism (PE) affects one in 1,000 people per year, and the increased utilization of CT scans since 2008 has resulted in more reported cases. The death rate of PE has coming down from 1979 to 1998 and it reveals that the death rate of this disease has been decreasing in the past several years. PE is related with DVT in 60-80% of patients and is usually asymptomatic and is the third leading cause of hospital- deaths with the overall estimate of 650,000 cases per year in the USA.
Venous thromboembolism may occur to approximately one individual in every 1,000 people every year and nearly 250,000 new cases occur in the United States annually.
Globally, the prevalence rate of PE also differs due to the inconsistency in diagnosing the condition.
It is revealed that the risk of PE in men is higher as compared to women causing 20 to 30 % higher mortality rates. VTE is more prevalent among male patients above 60 years of age, whereas PE is more common in female patients below 55 years of age. Black patients have higher PE incidence and mortality than white patients.
Pulmonary embolism (PE) can be defined as a condition that impacts on both the respiratory and the circulatory systems.
Respiratory Effects
PE leads to several acute respiratory issues, such as:
Increased alveolar dead space
Hypoxemia (low blood oxygen)
Hyperventilation
Other potential consequences include surfactant loss in certain regions, as well as pulmonary infarction. There are therefore four major causes of hypoxemia in patients with PE namely: V/Q mismatch, intrapulmonary shunt, reduction in the cardiac output, and an intracardiac shunt due to patent foramen ovale. Although pulmonary infarction is not common because of the anastomosis of bronchial arterial circulation.
Hemodynamic Effects
PE causes constriction of the pulmonary vasculature and decreases the cross-sectional area, thus increases pulmonary vascular resistance and RV afterload. This may result in right ventricular failure whenever the afterload reaches its maximum limit. Hormonal and reflex mechanisms also play a part in the constriction of pulmonary arteries. After anticoagulant therapy, the resolution of the emboli occurs within the first two weeks, however, some particles may remain embedded for as long as months to years, this may lead to chronic pulmonary hypertension if the embolus never dissolves or if recurrent emboli occur.
Venous Thromboembolism (VTE)
Deep Vein Thrombosis (DVT): About 90% of PE is caused by leg or pelvic vein blood clots that travel to the lungs.
Hypercoagulable States
Inherited Conditions: There are hereditary factors in clotting which include Factor V Leiden, prothrombin gene mutation as well as Protein C, Protein S, and Antithrombin deficiency.
Acquired Conditions: Risk of clot formation increases in conditions including but not limited to cancer, pregnancy, obesity, or when a person must stay immobile for long hours such as during flights, bed rest etc.
Surgery and Trauma
Major surgeries can result in the formation of venous clots because of immobility and due to the injuries on the blood vessels especially when the surgery involves operations such as the hip or knee operations.
Prolonged Immobility
Constant sitting or bed rest, for instance through hospitalization or an extensive journey result to what is referred to as oedema thus promoting clot formation.
Cancer
Some types of cancer such as the lung cancer or pancreatic and ovarian cancer and certain treatments like chemotherapy causes increase in clotting chances.
Hormonal Factors
Pregnancy and Postpartum Period: This is so due to hormonal changes experienced by pregnant women and must necessarily lead a relatively sedentary lifestyle due to their pregnancy.
Hormone Replacement Therapy (HRT) or Oral Contraceptives: Estrogen promotes hypercoagulable state, in other words influences the tendency to form blood clots.
The prognosis of pulmonary embolism (PE) varies with the state of health of the affected patient and the kind of management that the patient undergoes. Around 25 % of people with PE are prone to die suddenly. Mortality is subdivided into high risk and low or moderate risk. The use of anticoagulant therapy decreases the mortality rate to a level of below 5 percent with lung abnormities resolving in most persons after three months. If left untreated, PE has a 30% chance of being fatal.
A survey revealed that mortality of PE patients was 24% within one year and the main causes were heart failure, another PE, infection or cancer. Some biomarkers including natriuretic peptides and plasma lactate are associated with increased mortality. The mortality of HI-PE is 65%, intermediate risk is 5 to 25% and low risk has a 1% mortality.
Age Group
PE can occur at any age but is most prevalent in persons of 60 years and above. It is age related and the incidence rises with age. Children represent only a small proportion of reported infections but its association with the use of central venous catheter.
In pulmonary embolism (PE), physical examination may show tachycardia, tachypnea, hypoxemia, or signs of deep vein thrombosis. Respiratory changes observed might be Increased work of breathing, poor breath sounds or crackles. Some of the cardiovascular findings may be presence of jugular venous pulsation, right ventricular impulse, or increased intensity of the second heart sound. In severe conditions there may be cyanosis, cold and sweaty skin, DVT signs which include leg swelling and tenderness usually in the calf, extreme cold/blue toe syndrome. In some instances, the physical signs may be minimal or absent especially when the emboli are small.
Deep Vein Thrombosis (DVT): Deep vein thrombosis is closely related to PE as clots from the deep veins in the legs or pelvis can travel to the lungs.
Cancer: Patients with active cancer or receiving chemotherapy suddenly have increased coagulation, so they have a higher risk level.
Surgery or Trauma: Those patients with massive lower limb surgery such as the orthopedic or the abdominal ones, or the patients with major trauma are especially at risk owing to the immobility and the potential clot formation.
Pregnancy and Postpartum: Pregnancy brings hormonal changes and decreased mobility, and the risk is even higher in the postpartum period.
Acute presentation: This condition usually develops acutely and is potentially fatal if left untreated. Symptoms include:
Dyspnea is another related symptom which has sudden onset of shortness of breath.
Pleuritic Chest Pain: Sudden, stabbing pain with worsening on breathing.
Tachycardia: Cough, sometimes with hemoptysis
Syncope or Near-Syncope: May be seen in massive PE due to hemodynamic instability of the patient.
Subacute Presentation: Some patients may have slow presentation of the symptoms which may depend on the size, number or recurrence of the PEs which includes;
Low level of shortness of breath, tiredness, or feeling generally unwell for days to weeks.
Chronic Presentation: In some cases, PE can evolve into CTEPH with gradual development of exertional dyspnea, fatigue, and manifestations of right heart failure.
Angina Pectoris
Aortic Stenosis
Cardiogenic Shock
Dilated Cardiomyopathy
Acute Respiratory Distress Syndrome (ARDS)
Anxiety Disorders
Atrial Fibrillation
Cor Pulmonale
Fat Embolism
Hypersensitivity Pneumonitis
Myocardial Infarction
Emphysema
Mitral Stenosis
Initial Management
Surgical or Interventional Therapies:
Embolectomy: This is a surgical procedure where the blood clot is physically removed from the affected blood vessel, it is only conducted on patients with severe conditions where the use of thrombolytics cannot be done or have not worked as planned.
Catheter-Directed Thrombolysis: Technique whereby thrombolytics are directly infused through a catheter to the site of the clot in specific cases, massive PE.
Supportive Care:
Pain Management: Try to manage some amount of pain and discomfort, sometimes it even can be reduced with help of analgesics. Daily checks of general health, oxygen saturation and tolerance of treatment.
Pulmonary Medicine
Supportive Care: Supports for supplemental oxygen requirement to safeguard the adequate oxygen saturation levels and put off respiratory discomfort. However, in patients with severe hypoxemia or respiratory failure, the therapy may call for the use of a mechanical ventilator to assist in breathing.
Lifestyle and Preventive Measures: Promoting mobility and physical exercise in hospitalised patients especially of patients who have high risk of developing VTE minimises formation of new clots. To increase venous return and minimise the occurrence of DVT which causes PE, patients should be encouraged to wear intermittent pneumatic compression devices or graduated compression stockings.
Pulmonary Medicine
Enoxaparin (Lovenox): Enoxaparin is the first low molecular heparin with LMWH approved in the U. S., and this medication is applied to treat and prevent the development of deep vein thrombosis or pulmonary embolism. It achieves this by increasing the inhibitory effects of factor Xa and thrombin with the primary focus on factor Xa. It is utilised in pregnant women, but it is not clearly known which of the two; unfractionated heparin or low molecular weight heparin is safer. There is no need for monitoring PT or aPTT in patients receiving fondaparinux unlike conventional heparin, but factor Xa levels may be tested if required.
Dalteparin: It is another LMWH which is like enoxaparin but is used particularly for the prevention of DVT in patients who are undergoing abdominal surgery. It has a different dosing regimen but is also not dependent on routine PT or aPTT monitoring. Some patients may require the determination of Factor Xa levels especially if there is a doubt about the proper dosage.
Tinzaparin: It is an LMWH prescribed for the management of DVT in hospitalised patients. It boosts the action of antithrombin III through which it helps to inhibit factor Xa and thrombin effectively though it focuses on factor Xa inhibition.
Heparin: It increases the activity of antithrombin III to prevent conversion of fibrinogen to fibrin in a bid to check clot formation. It does not only bring dissolving of clots that are formed but it prevents the formation of new blood clots. For Unfractionated heparin (UFH) an assessment of aPTT should be done 6 hours after the first administration of the drug to check for appropriateness of dosage.
Warfarin: It inhibits the synthesis of vitamin K-dependent clotting factors hence used in the prevention and treatment of venous thromboembolism. It should only be initiated when the blood is adequately anticoagulated with heparin because of increased risk of clot propagation or recurrence.
Fondaparinux Sodium: It is a synthetic anticoagulant which has this mechanism of action among the factors of blood coagulation, it selectively targets factor Xa. It has good biological availability, a long-term clearance half live and gives long term anticoagulant effect. It does not have any influence on the prothrombin time interval and aPTT times as well as platelet function.
Pulmonary Medicine
Reteplase: It is second generation recombinant tissue plasminogen activator (tPA) which acts by activating plasminogen to plasmin and thereby helping in breakdown of clots. It is like alteplase for the opening of TIMI 2 or 3 at 90 minutes and can be administered as the single or the double bolus. It is faster and probably more effective in large or old thrombi due to it lower binding affinity for fibrin which allow better penetration into the clot. It is not approved by the FDA for use in pulmonary embolism, but it has been used off label especially where coronary dosing is applicable.
Alteplase: It is a recombinant tPA that it applied for acute myocardial infarction, ischemic stroke, and pulmonary embolism. In the emergency department, the medication is usually given through an infusion that takes 90-120 minutes for treatment of pulmonary embolism. The most common is a shortened 90-minute protocol that is considered even safer and more efficient. Because of such effects heparin therapy is normally given or continued after the infusion once the clotting tests go up to normal.
Pulmonary Medicine
Rivaroxaban: This drug is used for managing pulmonary embolism and for prevention of recurrent episodic after radical anticoagulation therapy for the first 6 months. It is also indicated for various venous thromboembolism (VTE) conditions, including:
Strategies for decreasing stroke and systemic embolism in nonvalvular atrial fibrillation. Therapeutic management of deep vein thrombosis (DVT)
Being an expert, it is your responsibility to ensure the patient does not have a repeat of DVT and PE. Prevention of DVT after joint arthroplasty for hip and knee ailments. Reducing the risk of VTE in the acutely ill medical patients with acceptable immobility (and low bleeding risk). Preventing death or myocardial infarction, revascularization, or amputation in coronary or peripheral artery disease
Apixaban: The above is recommended for the treatment of PE and can also be used in the prevention of the recurrence of this disease after 6 months of medication
Dabigatran: It is utilised for the management of DVT and PE in patients who have been given a parenteral anticoagulant for 5-10 days. It is also useful in prevention of recurrent DVT, and PE among patients who have previously undergone the treatment.
Edoxaban: It is a factor Xa inhibitor which is used for the Treatment of DVT and PE in patients who have undergone initial INR parenteral anticoagulation for 5-10 days.
Betrixaban: They are effective in the prevention of VTE in the hospitalized adult, with an acute medical illness and has moderate to severe immobility and other VTE risk factors.
Pulmonary Medicine
Thrombectomy: This procedure is done through the process of mechanical embolectomy where the blood clot is physically and surgically removed from the pulmonary arteries. It is mostly used for patients with massive PE or those who are not suitable candidates for thrombolytics. Thrombectomy can be done through using catheters (PTA or percutaneous thrombectomy) or through surgery.
Thrombolysis: Popularly called clot-busting therapy, this involves the delivery of thrombolytic agents to the clot to dissolve it. This approach is only applicable for patients with high risk or massive PE to achieve rapid clot resolution. The commonly used thrombolytic agents are alteplase (recombinant tissue plasminogen activator RT-PA) and reteplase. Fibrinolysis can be used in two ways, through systemic thrombolysis or through catheter directed thrombolysis.
Inferior Vena Cava (IVC) Filter Placement: An IVC filter is a filter placed within the inferior vena cava to catch blood clots and stop it from moving from the legs to the lungs. They are used in patients for whom anticoagulation therapy is contraindicated or in patients with recurrent embolism while on anticoagulation. The filter is normally deployed using a catheter deployed through the femoral or subclavian vein.
Surgical Embolectomy: This generally invasive method involves the surgical endovascular removal of the embolus from the pulmonary arteries. It is used in the management of massive PE when other forms of intervention cannot be performed or have proven ineffective. This operation is typically done in the operating theatre under general anesthesia.
Pulmonary Medicine
Acute Phase: The initial management entails the identification and control of factors that may worsen the condition of the patient. This frequently involves the use of anticoagulants which may include heparin, low molecular weight heparin (LMWH) for managing the acute event. In severe forms thrombolytic therapy or thrombectomy should be carried out for the faster dissolving of the blood clots.
Subacute Phase: The long-term management of patients involves the prescription of specific medications such as warfarin, rivaroxaban or apixaban to reduce the risk of such events in the future. Maintenance of therapeutic levels is also part of this phase to include consistent follow-ups for the same.
Chronic Phase: For long term management, patients may require continued use of anticoagulants, changes to their eating habits and the treatment of other associated risk factors. Common symptoms include dyspnoea, cough, chest pain, haemoptysis and tachycardia but one-third of patients may remain asymptomatic at presentation.
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