Pulmonary Disease

Answer 4 The patient is at increased risk for shock or death from PE and should receive more intensive monitoring. Most patients with PE will have a normal echocardiogram. When evidence of right ventricular strain is present, echocardiography reliably predicts an increased risk of death from PE. Even if patients are hemodynamically stable when the echocardiogram reveals right ventricular compromise, 10% of such patients will develop shock and 5% will die in the hospital.6 As such, patients with right ventricular strain should be initially monitored in the intensive care unit, even when hemodynamically stable. Although some physicians advocate more aggressive treatment for such patients (eg, thrombolytic therapy, vena caval interruption, higher target INR), none of these strategies has adequate data to support their use. Right ventricular strain was also recently shown to predict recurrent embolization;7 however, the use of different anticoagulation strategies based on this information has not been evaluated. REFERENCES 6. Grifoni S, Olivotto I, Cecchini P, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation 2000;101:2817-22. 7. Grifoni S, Vanni S, Magazzini S, et al. Association of persistent right ventricular dysfunction at hospital discharge after acute pulmonary embolism with recurrent thromboembolic events. Arch Intern Med 2006;166:2151-6. Click here to return to the questions

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