Pulmonary embolism classification

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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Pulmonary embolism can be classified based on the time course of symptom presentation (acute and chronic) and the overall severity of disease (stratified based upon three levels of risk: massive, submassive, and low-risk).

Classification Based on Acuity and Size

Acute Pulmonary Embolism

A pulmonary embolism is classified as acute if it meets any of the following criteria:

  • Silent
  • Symptomatic
  • Fatal

Acute PE are also classified as Massive pulmonary embolism or Submassive pulmonary embolism or Low-risk pulmonary embolism.

  • Time Criterion: Symptom onset and physical sign presentation occur immediately after obstruction of pulmonary vessels.
  • Embolus Size Criteria:
    • Embolus is located centrally within the vascular lumen.
    • Embolus occludes a vessel.
    • Embolus causes distention of the involved vessel.

Chronic Pulmonary Embolism

A pulmonary embolism is classified as chronic if it meets any of the following criteria:

  • Time Criterion: A markedly progressive development of dyspnea over time, generally as a result of pulmonary hypertension.
  • Embolus Size Criteria:[1]
    • Embolus is eccentric and contiguous with the vessel wall.
    • Embolus reduces the arterial diameter by ≥ 50%.
    • Evidence of recanalization within the thrombus.
    • Presence of an arterial web.

Classification Based on Disease Severity

In addition to the time of presentation and the size of the embolus, a pulmonary embolism can also be classified based on the severity of disease. Three major classifications exist: massive (5% of cases), submassive ( 40% of cases), and low-risk ( 55% of cases).

Massive Pulmonary Embolism

Submassive Pulmonary Embolism

  • Submassive pulmonary embolism patients share the following characteristics:[4][5]
    • A significantly higher rate of in-hospital complications.
    • A higher potential for long-term pulmonary hypertension and cardiopulmonary disease.
  • Though patients with submassive pulmonary emboli may initially appear hemodynamically and clinically stable, there is potential to undergo a cycle of progressive right ventricular failure. A submassive pulmonary embolism requires continuous monitoring to prevent irreversible damage and death.[6]

Saddle Pulmonary Embolism

  • A saddle pulmonary embolism is classified as an embolus that lodges at the bifurcation of the main pulmonary artery into the right and left pulmonary arteries.
  • Saddle pulmonary embolisms are typically classified as submassive.

Low-Risk Pulmonary Embolism

  • 55% of pulmonary emboli
  • The American Heart Association defines a low-risk pulmonary embolism as an acute pulmonary embolism without the life threatening clinical markers that define massive or submassive pulmonary emboli. [3]

References

  1. Castañer E, Gallardo X, Ballesteros E, Andreu M, Pallardó Y, Mata JM; et al. (2009). "CT diagnosis of chronic pulmonary thromboembolism". Radiographics. 29 (1): 31–50, discussion 50-3. PMID doi=10.1148/rg.291085061 19168835 doi=10.1148/rg.291085061 Check |pmid= value (help).
  2. Miller GA, Sutton GC, Kerr IH, Gibson RV, Honey M (1971). "Comparison of streptokinase and heparin in treatment of isolated acute massive pulmonary embolism". Br Heart J. 33 (4): 616. PMID 5557502.
  3. 3.0 3.1 3.2 Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.
  4. Ribeiro A, Lindmarker P, Johnsson H, Juhlin-Dannfelt A, Jorfeldt L (1999). "Pulmonary embolism: one-year follow-up with echocardiography doppler and five-year survival analysis". Circulation. 99 (10): 1325–30. PMID 10077516. Retrieved 2011-12-21. Unknown parameter |month= ignored (help)
  5. Fengler BT, Brady WJ (2009). "Fibrinolytic therapy in pulmonary embolism: an evidence-based treatment algorithm". Am J Emerg Med. 27 (1): 84–95. doi:10.1016/j.ajem.2007.10.021. PMID 19041539. Retrieved 2011-12-21. Unknown parameter |month= ignored (help)
  6. Cannon CP, Goldhaber SZ (1996). "Cardiovascular risk stratification of pulmonary embolism". Am. J. Cardiol. 78 (10): 1149–51. PMID 8914880. Retrieved 2011-12-21. Unknown parameter |month= ignored (help)

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