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Pulmonary Embolism

Pulmonary embolism is defined as a blockage of a pulmonary artery caused by a thrombus dislodged usually from the deep veins of the lower limbs.


Presentation

The typical presentation of the pulmonary embolism includes sudden onset of pleuritic chest pain, shortness of breath and hypoxia [7]. Most of the patients might have no clinical presentation at all. Symptoms may also vary from patient to patient. Hence, the diagnosis is made in the case of unexplained respiratory problems after excluding the other probable causes.

Other atypical symptoms include hemoptysis, productive cough, abdominal pain, flank pain, seizures, syncope, wheezing, fever and altered level of consciousness [8].

Cough
  • A 47-year-old woman with a medical history of Raynaud's phenomenon presented with fever, cough and shortness of breath. She was found to have left lower lobe consolidation and pleural effusion and was treated as a case of pneumonia.[ncbi.nlm.nih.gov]
  • Symptoms of PE include chest pain, shortness of breath, severe cough, coughing up of blood and even sudden death. Pulmonary embolism is the major concern for patients experiencing deep vein thrombosis (DVT) .[inovaheart.org]
  • Despite antibiotic therapy, he remained unwell with rising inflammatory markers, general malaise and persistent cough. He developed stony dull percussion and absent breath sounds to his left mid to lower zones.[ncbi.nlm.nih.gov]
  • One month prior to admission, he had developed persistent fever and cough and the diagnosis of CMV infection had been established.[ncbi.nlm.nih.gov]
  • The pain may become worse when you breathe deeply (pleurisy), cough, eat, bend or stoop. The pain will get worse with exertion but won't go away when you rest. Cough. The cough may produce bloody or blood-streaked sputum.[mayoclinic.org]
Dyspnea
  • The patient suffered dyspnea after undergoing the injection laryngoplasty. Chest embolism computed tomography (CT) scan revealed a new lesion of enhancing materials at the pulmonary vasculature in the right upper lobe.[ncbi.nlm.nih.gov]
  • He has been living well without dyspnea and the echocardiography showed the normalizations of the once increased pulmonary arterial pressure and the once enlarged right ventricle of his heart.[ncbi.nlm.nih.gov]
  • Herein, we report a case of high-risk APE with a wide range of manifestations, including chest pain, dyspnea, low-blood pressure, and syncope.[ncbi.nlm.nih.gov]
  • A 53-year-old man was admitted to the cardiology clinic with complaints of dyspnea, chest pain, and general weakness after walking. He had a history of hypertension and smoking.[ncbi.nlm.nih.gov]
  • A 71-year-old woman complained of dyspnea and swelling of the left lower limb. Computed tomography revealed filling defects in the pulmonary arteries and deep vein.[ncbi.nlm.nih.gov]
Pneumonia
  • She was found to have left lower lobe consolidation and pleural effusion and was treated as a case of pneumonia. During the hospital course, her respiratory status worsened, and she was intubated on the third hospital day.[ncbi.nlm.nih.gov]
  • We report an unusual presentation of pulmonary embolism (PE) where a 58-year-old man first developed symptoms of community-acquired pneumonia.[ncbi.nlm.nih.gov]
  • The diagnosis of pulmonary thromboembolism (PE) is often delayed because it is usually misdiagnosed as pneumonia or deep vein thrombosis.[ncbi.nlm.nih.gov]
  • It can mimic pneumonia, congestive heart failure, and a viral illness known as pleurisy.[vascularcures.org]
  • The major utility of the chest film is in finding other causes of the patient's symptoms (i.e. an infiltrate in pneumonia or absent lung markings in pneumothorax).[clinicaladvisor.com]
Hemoptysis
  • It manifests as pleural chest pain and hemoptysis. In contrast, multiple micro-emboli occlude the capillary beds of the lungs.[symptoma.com]
  • […] experience pulmonary embolism symptoms differently: sudden shortness of breath (most common) chest pain (usually worse with breathing) a feeling of anxiety a feeling of dizziness, lightheadedness, or fainting palpitations (heart racing) coughing up blood (hemoptysis[beaumont.org]
  • Simple, uncomplicated embolism produces such cardiopulmonary symptoms as dyspnea, tachypnea, persistent cough, pleuritic pain, and hemoptysis. Apprehension is a common symptom.[medical-dictionary.thefreedictionary.com]
  • She denies any cough, fever, sputum production or hemoptysis. She is married and had one normal delivery three years ago. She is currently on birth control pills. She has never been hospitalized except for labor and delivery.[meddean.luc.edu]
  • Most Common Symptoms : Dyspnea* Pleuritic chest pain* Cough Hemoptysis Leg pain Most Common Signs: Tachypnea* Tachycardia - This may be absent if taking AV nodal blocking medication (e.g., Beta blocker, Non-dihydropyridine calcium channel blocker) Rales[clinicaladvisor.com]
Tachypnea
  • A nine-year-old female with spinal muscular atrophy type 1, chronic respiratory failure with tracheostomy and ventilator dependence presented with tachypnea and hypoxia. She had recent coiling of her pulmonary arterio-venous malformation.[ncbi.nlm.nih.gov]
  • She had tachypnea, hypotension and tachycardia. Arterial blood gas analysis showed hypoxemia-hypocapnia and D-dimer level was high.[ncbi.nlm.nih.gov]
  • Tachypnea and tachycardia frequently are detected, pleuritic pain sometimes may be present, crackles may be heard in the area of embolization, and local wheeze may be heard rarely.[emedicine.medscape.com]
  • The most common are: Acute shortness of breath; Cough; Chest pain; Tachycardia; Tachypnea; Signs of DVT.[emsworld.com]
Swelling
  • A young man presented with the severe right upper limb swelling following a heavy weight lifting that was thought to be caused by a biceps tendon rupture.[ncbi.nlm.nih.gov]
  • A 71-year-old woman complained of dyspnea and swelling of the left lower limb. Computed tomography revealed filling defects in the pulmonary arteries and deep vein.[ncbi.nlm.nih.gov]
  • She present swell at knee and calf from postoperative 3 weeks, and developed dyspnea, palpitation, and nausea on 33th day, pulmonary embolism was confirmed with CT angiography at emergency department.[ncbi.nlm.nih.gov]
  • The diagnosis of venous thromboembolism is difficult in the postoperative setting because signs such as hypoxemia, leg pain, and swelling are so common.[ncbi.nlm.nih.gov]
  • Symptoms of a blood clot include warmth, swelling, pain, tenderness and redness of the leg. What are the treatments for a pulmonary embolism (PE)? The goal of treatment is to break up clots and help keep other clots from forming.[medlineplus.gov]
Fever
  • High grade fever is a rare presentation of thromboembolic phenomenon. A middle aged woman presented with high grade fevers. Patient remained febrile despite broad spectrum antibiotics. All cultures were negative.[ncbi.nlm.nih.gov]
  • A 62-year-old male developed fever of unknown origin.[ncbi.nlm.nih.gov]
  • A 47-year-old woman with a medical history of Raynaud's phenomenon presented with fever, cough and shortness of breath. She was found to have left lower lobe consolidation and pleural effusion and was treated as a case of pneumonia.[ncbi.nlm.nih.gov]
  • One month prior to admission, he had developed persistent fever and cough and the diagnosis of CMV infection had been established.[ncbi.nlm.nih.gov]
  • A 14-year-old girl with no previous significant medical history was referred to the ED with pleuritic and chest pain with low-grade fever 4 days before admission. Echography showed a small amount of left pleural effusion.[ncbi.nlm.nih.gov]
Congestive Heart Failure
  • As a result of another medical condition, such as cardiovascular disease (including congestive heart failure, atrial fibrillation and heart attack) or stroke. When clotting factors in the blood are increased, elevated, or in some cases, lowered.[my.clevelandclinic.org]
  • It can mimic pneumonia, congestive heart failure, and a viral illness known as pleurisy.[vascularcures.org]
  • Risk factors include: prolonged bed rest, surgery, childbirth , heart attack, stroke, congestive heart failure , cancer, obesity, a broken hip or leg, oral contraceptives , sickle cell anemia, congenital coagulation disorders , chest trauma, certain congenital[medical-dictionary.thefreedictionary.com]
  • heart failure, liver failure, or high bleeding risk Clinical practice guidelines recommend 10 mg orally once daily for the first 2 days for patients healthy enough to be treated as outpatients Warfarin should be started on the same day as heparin, low-molecular-weight[aafp.org]
  • ., prolonged immobilization or congestive heart failure).[clinicaladvisor.com]
Prolonged Immobilization
  • Venous thromboembolism may result from prolong immobilization following intracerebral hemorrhage.[ncbi.nlm.nih.gov]
  • Examples of these include: Prolonged immobilization Extended travel (sitting in a car, airplane, train, etc.)[medicinenet.com]
  • ., prolonged immobilization or congestive heart failure).[clinicaladvisor.com]
  • A large pulmonary embolism is usually fatal and is a much-feared complication of recent surgery or pregnancy with prolonged immobilization and inadequate movement of the limbs.[medical-dictionary.thefreedictionary.com]
  • immobilization of 1 week or longer; active cancer (i.e., recurrent or metastasized cancer or cancer that had been treated with chemotherapy or radiotherapy in the previous 6 months); and history of venous thromboembolism.[nejm.org]
Chest Pain
  • The chest pain remained at the same level. On the day of admission, she presented to ED with vomiting, watery diarrhea, abdominal pain, chest pain, and respiratory distress. Laboratory findings showed hypoalbuminemia and proteinuria.[ncbi.nlm.nih.gov]
  • We described a 59-year-old man who presented to emergency department complaining of chest pain. He was suffered acute myocardial infarction (MI) and pulmonary embolism (PE) simultaneously.[ncbi.nlm.nih.gov]
  • Herein, we report a case of high-risk APE with a wide range of manifestations, including chest pain, dyspnea, low-blood pressure, and syncope.[ncbi.nlm.nih.gov]
  • A 53-year-old man was admitted to the cardiology clinic with complaints of dyspnea, chest pain, and general weakness after walking. He had a history of hypertension and smoking.[ncbi.nlm.nih.gov]
  • We present a 58-year-old woman patient with a history of tongue carcinoma who was admitted in emergency department for sudden chest pain.[ncbi.nlm.nih.gov]
Tachycardia
  • She had tachypnea, hypotension and tachycardia. Arterial blood gas analysis showed hypoxemia-hypocapnia and D-dimer level was high.[ncbi.nlm.nih.gov]
  • Tracheobronchomalacia is an uncommon condition, which presents with similar symptoms to pulmonary embolism, including hypoxemia, tachycardia, and shortness of breath.[ncbi.nlm.nih.gov]
  • Dyspnea (79%) and tachycardia (68%) were the commonest symptom and sign, respectively. D dimer was positive in 96.2% of the cases while nonspecific T inversion in the ECG was seen in 54.7% of the patients.[ncbi.nlm.nih.gov]
  • Increased RV loading causes compensatory RV dilation, impaired contractility, tachycardia, and sympathetic activation.[ncbi.nlm.nih.gov]
  • Tachycardia and high D-dimer (21.27 mg/L fibrinogen-equivalent units) were noted. Chest computed tomography showed bilateral pulmonary trunk embolism.[ncbi.nlm.nih.gov]
Hypotension
  • Ultimately, insufficient cardiac output from the RV causes left ventricular under-filling which results in systemic hypotension and cardiovascular collapse.[ncbi.nlm.nih.gov]
  • This case report describes a patient with intraoperative PE presenting with hypotension and hypoxemia for whom the ECG finding of SIQIIITIII was key in identifying acute cor pulmonale.[ncbi.nlm.nih.gov]
  • A 30-year-old man collapsed with massive PE 3 days after an exploratory laparotomy for penetrating trauma, and he remained hypoxic and hypotensive despite thrombolytic therapy.[ncbi.nlm.nih.gov]
  • ., shock or hypotension), should receive systemically administered thrombolytic therapy.[ncbi.nlm.nih.gov]
  • She had tachypnea, hypotension and tachycardia. Arterial blood gas analysis showed hypoxemia-hypocapnia and D-dimer level was high.[ncbi.nlm.nih.gov]
Cyanosis
  • […] obstruction of a pulmonary artery or one of its branches that is usually produced by a blood clot which has originated in a vein of the leg or pelvis and traveled to the lungs and that is marked by labored breathing, chest pain, fainting, rapid heart rate, cyanosis[merriam-webster.com]
  • The extremities reveal no evidence of edema, cyanosis or clubbing. Patient has negative Homan's Sign. Joint exam revealed shoulder movements complete in range. No warmth or tenderness noted.[meddean.luc.edu]
  • Pay close attention to the patient's skin; diaphoresis and clammy skin are common, and peripheral cyanosis in the hands and feet may rapidly progress to central cyanosis on the face, neck and trunk.[emsworld.com]
  • It is characterized by dyspnea, anxiety, sudden chest pain, shock, and cyanosis.[medical-dictionary.thefreedictionary.com]
  • Other signs and symptoms that can occur with pulmonary embolism include: Leg pain or swelling, or both, usually in the calf Clammy or discolored skin (cyanosis) Fever Excessive sweating Rapid or irregular heartbeat Lightheadedness or dizziness When to[mayoclinic.org]
Homans' Sign
  • Patient has negative Homan's Sign. Joint exam revealed shoulder movements complete in range. No warmth or tenderness noted.[meddean.luc.edu]
  • Eliciting Homans' sign (discomfort behind the knee on forced dorsiflexion of the foot), noting skin and temperature changes in the area of the calf, and assessing edema of the extremities are important monitoring activities in the care of patients at[medical-dictionary.thefreedictionary.com]
Back Pain
  • Some individuals may also experience uncommon symptoms such as dizziness, back pain or wheezing. Because PE can be fatal, if you experience these signs or symptoms seek medical attention right away.[vascularcures.org]
  • But as the week progressed so did her symptoms — back pain, chest pain, uncontrollable chills — until she could no longer ignore them.[heartinsight.heart.org]
Dizziness
  • However, each individual may experience symptoms differently: Sudden shortness of breath (most common) Chest pain, usually worse with breathing A feeling of anxiety A feeling of dizziness, lightheadedness, or fainting Palpitations and heart rarcing Coughing[inovaheart.org]
  • However, each individual may experience pulmonary embolism symptoms differently: sudden shortness of breath (most common) chest pain (usually worse with breathing) a feeling of anxiety a feeling of dizziness, lightheadedness, or fainting palpitations[beaumont.org]
  • Other symptoms include: swelling of one or both legs, usually in the calf clammy skin fever and sweating feeling lightheaded or dizzy .[healthdirect.gov.au]
  • Some individuals may also experience uncommon symptoms such as dizziness, back pain or wheezing. Because PE can be fatal, if you experience these signs or symptoms seek medical attention right away.[vascularcures.org]
  • […] may be no symptoms at all; in more extensive clot formation, the patient may experience sudden symptoms such as difficulty breathing, chest pain (similar to a heart attack or angina), a blood-streaked cough, and a general feeling of uneasiness with dizziness[uspharmacist.com]
Panic Attacks
  • It may be hard to diagnose pulmonary embolism, because the symptoms are like those of many other problems, such as a heart attack , a panic attack , or pneumonia .[uofmhealth.org]

Workup

The history and clinical examination of a case of pulmonary embolism are usually not sufficient to establish the diagnosis of pulmonary embolism with certainty. Hence, in cases of unexplained respiratory problems, certain investigations must be carried out to reach the final diagnosis [9].

A hypercoaguable workup must be carried out to screen for antithrombin 3 deficiency, protein C or protein S deficiency, connective tissue disorders and homocystinurea.

White blood count, arterial blood gases, D dimer testing, brain natriuretic peptide, serum troponin levels and ischemia modified albumin level are potentially useful laboratory tests that can indicate the presence or absence of pulmonary embolism in the patient.

Imaging techniques that are helpful in confirming the diagnosis of pulmonary embolism include computed tomography angiography, pulmonary angiography, chest radiography, ECG, magnetic resonance imaging (MRI), venography and duplex ultrasonography.

Left Pleural Effusion
  • Echography showed slight increase in left pleural effusion. She had the same diagnosis. The chest pain remained at the same level.[ncbi.nlm.nih.gov]
Normal Chest X-Ray
  • A normal chest X-ray greatly increases the likelihood of a definitive VQ scan result.[clinicaladvisor.com]
Right Axis Deviation
  • The most commonly seen signs in the ECG are sinus tachycardia , right axis deviation, and right bundle branch block . [58] Sinus tachycardia, however, is still only found in 8–69% of people with PE. [59] ECG findings associated with pulmonary emboli may[en.wikipedia.org]
Thrombocytosis
  • Other conditions include polycythemia, paroxysmal nocturnal hemoglobinuria and essential thrombocytosis amongst others.[myheart.net]
  • […] trips or hospitalization), pregnancy, use of estrogen-containing hormonal contraceptives, postmenopausal hormones, atrial fibrillation, vascular injury, IV drug abuse, polycythemia vera, heart failure, autoimmune hemolytic anemia, sickle cell anemia, thrombocytosis[medical-dictionary.thefreedictionary.com]
  • […] factors resulting in a hypercoagulable state Acute medical illness Drug abuse (intravenous [IV] drugs) Drug-induced lupus anticoagulant Hemolytic anemias Heparin-associated thrombocytopenia Homocystinemia Homocystinuria Hyperlipidemias Phenothiazines Thrombocytosis[emedicine.medscape.com]
  • […] factors Risk factors for pulmonary embolism also include the following: Drug abuse (intravenous [IV] drugs) Drug-induced lupus anticoagulant Hemolytic anemias Heparin-associated thrombocytopenia Homocystinemia Homocystinuria Hyperlipidemias Phenothiazines Thrombocytosis[emedicine.medscape.com]
Hypocapnia
  • Arterial blood gas analysis showed hypoxemia-hypocapnia and D-dimer level was high. Computed tomographic pulmonary angiography (CTPA) demonstrated pulmonary embolism in both main pulmonary arteries, through lobar and segmental branches.[ncbi.nlm.nih.gov]
  • Analysis of blood gases reveals arterial hypoxia and hypocapnia. Pulmonary embolism is detected by chest radiographic films, pulmonary angiography, and radioscanning of the lung fields.[medical-dictionary.thefreedictionary.com]
Decreased Oxygen Saturation
  • oxygen saturation (red blood cells that do not have oxygen molecules attached to them) Decreased blood pressure: hypotension (hypo low tension pressure) The condition progresses as follows: The heart rate and respiratory rate may elevate as the body[medicinenet.com]
Pleural Effusion
  • Echography showed a moderate amount of pleural effusion on both sides and no dilatation of the right cardiac ventricle.[ncbi.nlm.nih.gov]
  • In this paper, we will describe an uncommon presentation of lung cancer on a non-smoker middle-aged woman, with recent diagnosis of pulmonary embolism, who develops malignant recurrent pleural effusion, NBTE with cutaneous and neurological manifestations[ncbi.nlm.nih.gov]
  • She was found to have left lower lobe consolidation and pleural effusion and was treated as a case of pneumonia. During the hospital course, her respiratory status worsened, and she was intubated on the third hospital day.[ncbi.nlm.nih.gov]
  • Additional Studies Lung scan revealed a defect corresponding to the area of pleural effusion. Pleural tap revealed yellow fluid; protein 3.5 grams; glucose 64 and pH 7.4.[meddean.luc.edu]
  • Signs that may be present in PE are; Westermark's sign (oligemia in area of involvement), increased size of a hilum (caused by thrombus impaction), atelectasis with elevation of hemidiaphragm and linear or disk shaped densities, pleural effusion, consolidation[med-ed.virginia.edu]

Treatment

In patients with suspected deep venous thrombosis or pulmonary embolism, anti-coagulant therapy is initiated immediately [10].

Anticoagulant therapy with heparin administration decreases the mortality rate from 30% to less than 10%. Various anti-coagulation medications include unfractionated heparin, low weight heparin, warfarin, fondaparinux and factor Xa inhibitors.

Thrombolytic agents such as alteplase/reteplase and urokinase/streptokinase are also used in the treatment of pulmonary embolism.

Surgical options for management of pulmonary embolism include:

  • Catheter embolectomy and fragmentation or surgical embolectomy
  • Placement of vena cava filters

Along with these treatment options, supportive care to the patient is ensured.

Prognosis

As far as the common causes of sudden death are concerned, pulmonary embolism is second only to sudden cardiac death.

Up to 10% of the patients who develop pulmonary embolism die within the first hour. Recurrence of pulmonary embolism subsequently causes death in 30% of the patients.

With appropriate anti-coagulant therapy, the mortality rate reduced to less than 5%.

Etiology

More than 90% of the pulmonary emboli result from the dislodging of thrombi from the deep veins of the lower limb. Other less common sites of thrombus formation include prostatic and pelvic veins. Pulmonary emboli usually do not originate in the upper limb except in intravenous drug abusers.

The factors that predispose to venous thrombosis in the lower limbs include the following.

Venous stasis:

Venous trauma:

  • Trauma
  • Intravenous cannulation

Increased coagubility:

Inherited coagulation defects:

Miscellaneous:

  • Smoking [2]

Epidemiology

The per annum incidence of pulmonary embolism in the United States is 1 case per 1000 persons [3]. Although most of these patients are asymptomatic, 60-80% of the patients with DVT develop pulmonary embolism.

In hospitalized patients, pulmonary embolism is the third most common cause of death (up to 650,000 deaths per year). Venous thromboembolism is a major health problem with an incidence of about 250,000 incident cases per year [4] [5].

The incidence of pulmonary embolism and the mortality occurring from it varies from country to country. A research indicates that male sex is more prone to the development of pulmonary embolism with a mortality rate 20-30% higher as compared to females. Pulmonary embolism is much more common in blacks as compared to whites [6].

Sex distribution
Age distribution

Pathophysiology

Pulmonary emboli arise most commonly from the deep veins of the calves. Any factor or disease that cases stasis of blood in the veins can predispose to the formation of thrombi. Dislodged thrombi reach the lung after traveling through the right side of the heart.

Large emboli occlude the proximal arteries and the right ventricular outflow, causing a rapid decrease in the the cardiac output and leading to right ventricular failure. The prominent features are those of vascular collapse e.g. hypotension and syncope.

On the other hand, small and medium sized emboli occlude the segmental arteries causing infarction of the lung segment involved. It manifests as pleural chest pain and hemoptysis.

In contrast, multiple micro-emboli occlude the capillary beds of the lungs. Due to collateral vascular supply, there is no pulmonary infarction  but there insidious loss of the microvascular bed supplying the gas exchange units of the lungs leading to pulmonary hypertension and right ventricular failure.

Prevention

Prevention of the development of venous thromboembolism can effectively reduce the likelihood of the development of pulmonary embolism. This is done by the following measures:

Avoid venous stasis:

Venous stasis during surgery can be avoided by stimulation of the calf muscles. Following surgery, early mobilization and leg exercises are helpful in reducing the likelihood of venous thromboembolism.

Use of anticoagulants in susceptible individuals:

Anticoagulants such as warfarin and heparin are used in the patients who are at high risk for developing thromboembolism.

Summary

Pulmonary emboli are thrombi that dislodge into the lungs usually from the deep veins of the lower limbs. Less common sites of thrombus formation include the veins of the pelvis, prostate and the upper limbs.

Pulmonary emboli may be small, medium or large. Each of these cause respiratory and hemodynamic compromise by different mechanisms. Hence, pulmonary embolism is not a disease; rather it is the complication of deep venous thrombosis (DVT).

It is a life threatening emergency and needs to be diagnosed and treated promptly.

Patient Information

Pulmonary embolism refers to the state in which masses of clotted blood that form in the lower limbs dislodge into the lungs. Males are more prone to the development of this complication.

Smoking, obesity, decreased physical activity and intake of unbalanced diet make the person more prone to the development of pulmonary embolism. It is a very dangerous condition and the patient needs to be hospitalized immediately. High risk patients must be identified and preventive measures must be carried out.

References

Article

  1. Malek J, Rogers R, Kufera J, Hirshon JM. Venous thromboembolic disease in the HIV-infected patient. The American journal of emergency medicine. Mar 2011;29(3):278-282.
  2. Stein PD, Beemath A, Matta F, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. The American journal of medicine. Oct 2007;120(10):871-879.
  3. Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data. Archives of internal medicine. Jul 28 2003;163(14):1711-1717.
  4. Heit JA. The epidemiology of venous thromboembolism in the community: implications for prevention and management. Journal of thrombosis and thrombolysis. Feb 2006;21(1):23-29.
  5. Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ, 3rd. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Archives of internal medicine. Mar 23 1998;158(6):585-593.
  6. Schneider D, Lilienfeld DE, Im W. The epidemiology of pulmonary embolism: racial contrasts in incidence and in-hospital case fatality. Journal of the National Medical Association. Dec 2006;98(12):1967-1972.
  7. Worsley DF, Alavi A. Comprehensive analysis of the results of the PIOPED Study. Prospective Investigation of Pulmonary Embolism Diagnosis Study. Journal of nuclear medicine : official publication, Society of Nuclear Medicine. Dec 1995;36(12):2380-2387.
  8. Carrascosa MF, Batan AM, Novo MF. Delirium and pulmonary embolism in the elderly. Mayo Clinic proceedings. 2009;84(1):91-92.
  9. Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Revista espanola de cardiologia. 2008;61(12):1330.
  10. Kearon C, Kahn SR, Agnelli G, et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):454S-545S.

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Last updated: 2018-06-22 05:55