DIAGNOSIS AND TREATMENT OF PULMONARY-EMBOLISM

Pulmonary thromboembolism is a common disease occurring most often as a complication in hospitalized patients, and is the third most frequent cause of death in the United States. Although the exact incidence of the disease is not known, based on our own and other studies, fatal pulmonary embolism can be estimated to occur in about 150,000 patients and nonfatal pulmonary embolism in about 600,000 patients per year. The incidence continues to rise in spite of advances in diagnosis and therapy. Untreated pulmonary embolism carries a high (18 to 38%) mortality rate, but once it is recognized and treated a substantial reduction in mortality (8.3%) occurs. This observation underscores the importance of early diagnosis and prompt treatment. Diagnosis of pulmonary embolism usually rests on clinical suspicion in the proper setting and confirmation by appropriate laboratory tests. Major diagnostic problems that the physician faces are: that pulmonary embolism can and does occur with few or minimal physical findings and may be mistaken for other cardiopulmonary disorders such as congestive heart failure, pneumonia, and atelectasis; that common laboratory tests usually yield nonspecific results; and that the more specific studies like V/Q lung scanning and selective pulmonary angiography are expensive and not readily available. Therapeutic considerations include mode of heparinization, duration of anticoagulant treatment, and the role of thrombolytic agents and surgery. The following is an effort to evaluate features of history and physical findings that are of diagnostic aid, to assess the specificity and sensitivity of laboratory tests, and to discuss the therapeutic approach with emphasis on recent advances.