**9. References**


et al., 2010). In addition, patients who presented with a first symptomatic PE are at a 4-fold increased risk of recurrent symptomatic PE compared to patients who presented with deep

In patients with recurrent PE or progressive deep venous thrombosis (DVT) despite adequate anticoagulation therapy, inferior vena cava (IVC) filters may be indicated. IVC filter placement is generally accepted in patients with massive PE or limited cardiopulmonary reserve and DVT. Current evidence indicates that IVC filters are largely effective, with breakthrough PE occurring in only 0% to 6.2% cases. Recurrent PE, IVC thrombosis, filter migration, filter fracture, or penetration of caval wall can sometimes occur

Risk stratification of acute PE is fundamental not only to select an appropriate treatment strategy, but also to potentially reduce costs of management (Figure 2). An appropriate risk stratification algorithm would include clinical, imaging and biomarkers. High risk PE is diagnosed in the presence of shock or persistent hypotension and should warrant urgent management. Thrombolysis with alteplase (rtPA), streptokinase, or urokinase is the recommended therapy. Embolectomy could represent an alternative therapy for patients

Hemodynamically stable patients without RV dysfunction or myocardial injury are at lowrisk for PE-related adverse events. These patients may be eligible for early hospital

In the remaining normotensive patients, a plausible strategy is to combine biomarkers with echocardiography. The presence of RV dysfunction and myocardial injury identifies patients

Whether intermediate risk patients will have any survival benefit with early initiation of reperfusion therapy (and what type of therapy) is not well accepted. Current recommendations proposed thrombolysis be instituted in selected patients at high risk for adverse events without contraindications (Grade IIB ESC and ACCP VIII Edition), and intravenous unfractionated heparin should be reserved to conditions in which thrombolysis is contraindicated (Grade IA ESC and ACCP VIII Edition). An ongoing study assessing the benefit of thrombolysis as compared with anticoagulation in hemodynamically stable patients with evidence of RV dysfunction and an elevated troponin levels will hopefully

Araoz PA, Gotway MB, Harrington JR, Harmsen WS, Mandrekar JN. Pulmonary embolism:

Aujesky D, Roy PM, Le Manach CP, Verschuren F, Meyer G, Obrosky DS et al. Validation

Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary

Binder L, Pieske B, Olschewski M, Geibel A, Klostermann B, Reiner C, Konstantinides S. N-

of a model to predict adverse outcomes in patients with pulmonary embolism. Eur

terminal pro-brain natriuretic peptide or troponin testing followed by

prognostic CT findings. Radiology 2007;242:889.

embolism: a meta-analysis. Circulation 2007;116(4):427.

venous thrombosis without symptoms of PE (Eichinger et al., 2004).

with shock in the acute setting when thrombolysis has been unsuccessful.

with long-term use (Chung et al., 2008).

discharge or even outpatient treatment.

provide some insights (NCT00639743).

Heart J 2006;27:476–481.

**8. Conclusion** 

at intermediate risk.

**9. References** 

echocardiography for risk stratification of acute pulmonary embolism. Circulation. 2005 Sep 13;112(11):1573-9. Epub 2005 Sep 6.


Risk Stratification of Patients with Acute Pulmonary Embolism 35

Müller-Bardorff M, Weidtmann B, Giannitsis E, Kurowski V, Katus HA. Release kinetics of

Pieralli F, Olivotto I, Vanni S, Conti A, Camaiti A, Targioni G, Grifoni S, Berni G. Usefulness

Pruszczyk P, Kostrubic M, Bochowicz A, Styczynski G, Szulc M, Kurzyna M et al. N

Pruszczyk P, Pacho R, Ciurzynski M et al. Short term clinical outcome of acute saddle

Puls M, Dellas C, Lankeit M, et al. Heart-type fatty acid-binding protein permits early risk

Qanadli SD, El Hajjam M, Viellard-Baron A, et al. New CT index to quantify arterial

Quiroz R, Kucher N, Schoepf UJ, Kipfmueller F, Solomon SD, Costello P, et al. Right

Ribeiro A, Lindmarker P, Johnsson H, Juhlin-Dannfelt A, Jorfeldt L. Ribeiro A, Lindmarker

Ribeiro A, Lindmarker P, Juhlin-Dannfelt A, Johnsson H, Jorfeldt L. Echocardiography

Ryu JH, Pelikka PA, Froehling DA, Peters SG, Aughenbaugh GL. Saddle pulmonary

Sanchez O, Trinquart L, Colombet I, Durieux P, Huisman MV, Chatellier G, Meyer G.

Schoepf UJ, Kucher N, Kipfmueller F, Quiroz R, Costello P, Goldhaber SZ. Right ventricular

Ten Wolde M, Tulevski II, Mulder JW, Sohne M, Boomsma F, Mulder BJ et al. Brain

stratification of pulmonary embolism. Eur Heart J 2007;28:224.

Chem. 2002;48(4):673-5.

embolism. Am J Cardiol 2006;97:1386–1390.

pulmonary embolism. Heart 2003; 89: 335–336.

echocardiography. Am J Roentgenol 2001;176:1415.

pulmonary embolism. Circulation 2004;109:2401.

Circulation. 1999 Mar 16;99(10):1325-30.

Respir Med 2007;101:1537.

2008;29:1569.

mortality rate. Am Heart J. 1997;134:479-487.

pulmonary embolism. Arch Intern 2004;164:1685.

The urokinase pulmonary embolism trial. JAMA 1970; 214:2163-72

embolism. Circulation 2003;107:2082.

embolism. Eur Respir J 2003;22:649.

cardiac troponin T in survivors of confirmed severe pulmonary embolism. Clin

of bedside testing for brain natriuretic peptide to identify right ventricular dysfunction and outcome in normotensive patients with acute pulmonary

terminal pro-brain natriuretic pepetide in patients with acute pulmonary

obstruction in pulmonary embolism: comparison with angiographic index and

ventricular enlargement on chest computed tomography: prognostic role in acute

P, Johnsson H, Juhlin-Dannfelt A, Jorfeldt L. Pulmonary embolism: one-year follow-up with echocardiography doppler and five-year survival analysis.

Doppler in pulmonary embolism: right ventricular dysfunction as a predictor of

embolism diagnosed by CT angiography: frequency, clinical features and outcome.

Prognostic value of right ventricular dysfunction in patients with hemodynamically stable pulmonary embolism: a systemic review. Eur Heart J

enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism. Circulation. 2004 Nov 16;110(20):3276-80. Epub 2004 Nov 8. Ten Wolde M, Söhne M, Quak E, Mac Gillavry MR, Büller HR. Prognostic value of

echocardiographically assessed right ventricular dysfunction in patients with

natriuretic peptide as a predictor of adverse outcome in patients with pulmonary


Jiménez D, Díaz G, Marín E, Vidal R, Sueiro A, Yusen RD. The risk of recurrent venous

thromboembolism in patients with unprovoked symptomatic deep vein thrombosis and asymptomatic pulmonary embolism. Thromb Haemost. 2006 Mar;95(3):562-6. Jiménez D, Díaz G, Molina J, Martí D, Del Rey J, García-Rull S, Escobar C, Vidal R, Sueiro A,

Yusen RD. Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism. Eur Respir J. 2008 Apr;31(4):847-53. Epub 2007 Dec 19. Jiménez D, Yusen RD, Otero R, Uresandi F, Nauffal D, Laserna E, Conget F, Oribe M,

Cabezudo MA, Díaz G. Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy. Chest. 2007;132(1):24-30. Kaczyńska A, Pacho R, Bochowicz A et al. Does saddle embolism influence short-term

prognosis in patients with acute pulmonary embolism? Kardiol Pol, 2005; 62: 119–

heart-type fatty acid binding protein is superior to troponin and myoglobin for rapid risk stratification in acute pulmonary embolism. Clin Chim Acta.

right ventricular afterload stress detected by echocardiography in patients with

adverse outcome in patients with pulmonary embolism: a systematic review and

HW, Huisman MV. Patient outcomes after acute pulmonary embolism. A pooled survival analysis of different adverse events. Am J Respir Crit Care Med. 2010 Mar

ovale is an important predictor of adverse outcome in patients with major

natriuretic peptide levels predict benign clinical outcome in acute pulmonary

acute PE and a systemic arterial pressure of 90mmHg or higher. Arch Intern Med

ventricular dysfunction detected by echocardiography in acute pulmonary

Kaczynska An, Pelsers MM, Bochowicz A, Kostrubiec M, Glatz JF, Pruszczyk P. Plasma

Kasper W, Konstantinides S, Geibel A, Tiede N, Krause T, Just H. Prognostic significance of

Klok FA, Mos IC, Huisman MV. Brain-type natriuretic peptide levels in the prediction of

Klok FA, Zondag W, van Kralingen KW, van Dijk AP, Tamsma JT, Heyning FH, Vliegen

Konstantinides S, Geibel A, Kasper W, Olschewski M, Blumel L, Just H. Patent foramen

Kostrubiec M, Pruszczyk P, Kaczynska A, Kucher N. Persistent NT-proBNP elevation in acute pulmonary embolism predicts early death. Clin Chim Acta 2007;382:124. Kucher N, Printzen G, Doernhoefer T, Windecker S, Meier B, Hess OM. Low pro-brain

Kucher N, Printzen G, Goldhaber SZ. Prognostic role of brain natriuretic peptide in acute

Kucher N, Rossi E, De Rosa M, et al. Prognostic role of echocardiography in patients with

Lega JC, Lacasse Y, Lakhal L, Provencher S. Natriuretic peptides and troponins in

McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right

pulmonary embolism: a meta-analysis. Thorax. 2009;64(10):869.

clinically suspected pulmonary embolism. Heart. 1997;77:346-349.

meta-analysis. Am J Respir Crit Care Med. 2008;178(4):425.

127.

2006;371:117.

2005;165:1777.

1;181(5):501-6. Epub 2009 Dec 3.

pulmonary embolism. Circulation 1998;97:1946.

embolism. Circulation 2003;107:1576–1578.

pulmonary embolism. Circulation 2003;107:2545.

embolism. Am J Cardiol. 1996 Aug 15;78(4):469-73.


**3** 

*Czech Republic* 

**Pulmonary Embolism in the Elderly –** 

*Department of Internal Medecine, Geriatrics and Practical Medicine* 

Pavel Weber, Dana Weberová, Hana Kubešová and Hana Meluzínová

The development of civilization and extreme technical progress leads to increasing hope of longer survival and makes the average life expectancy longer. Both in absolute and relative numbers the amount of the elderly, very old and long-aged people are increasing (Blackburn & Dulmus, 2007; Ratnaike, 2002). This tendency will continue and it will be emphasized by ageing volumes of people born after the World War 2 in the years 2010 -2015 (Kalvach et al., 2004). The basic survey and knowledge of geriatric medicine will be necessary in the future, especially for professionals such as doctors, nurses, psychologists,

Knowledge of at least basic extraordinarities and specifics of geriatric medicine will be of huge practical significance, because in the year 2050 there will live 2 billions of people older than 60 years on the Earth. (Moody, 2009). From this fact it is obvious, that there is an objective need to master the basic knowledge of gerontology and geriatry among

In this brief chapter it is not possible to include the whole issue dealing with the medical care of old-aged patients with PE, even if this issue deserves the attention because of its practical meaning and close relationship with other branches (internal medicine, surgery etc.). The emergency situations together with polymorbidity and exhaustion of functional reserves in advanced age (Campbell et al., 2008; Friedman et al., 2008) will be more frequent in all of the organ systems – cardiovascular, respiratory, GI (gastrointestinal) tract, endocrine, immune etc. (Bongard & Sue, 2003; Roberts & Hedges, 2009). We refer to the study of the clinical picture description (incl.therapy) of each of critical states in the old age in appropriate specialized chapters in this monograph and in other gerontologic literature

General knowledge of these aspects can substantially influence an approach of intensivists who face an increasing number of old patients in their practice (Brunner-Ziegler et al., 2008; Pathy et al., 2006). Among the aspects we would like to mention there are: global situation, specific problem of geriatric medicine, pharmacotherapy in the elderly, at last but not least problems of ageing organism as reflected in particularities and pitfalls of medical treatment

Ageing and its manifestation as currently understood such as frailty, functional disorders and decreasing mental abilities are not standard symptoms of ageing process but they are

social workers, physio- and occupational therapists etc.

professionals (including doctors of all medical branches).

(Hall et al., 2005; Stone & Humphries, 2004).

in multi-morbid old patients.

**1. Introduction** 

**Significance and Particularities** 

*Masaryk University and University Hospital, Brno* 

