Long-term prognosis of treated acute massive pulmonary embolism.

Abstract

Seventy-two patients surviving initial treatment by pulmonary embolectomy, streptokinase, or heparin for acute massive pulmonary embolism have been reviewed 1 to 9years later. Of these patients, 17 had additional cardiorespiratory disease. There were 12 late deaths (41% of those patients with, and 9% of those patients without additional cardiorespiratory disease). No death was due to chronic pulmonary hypertension, and none to certain recurrence of pulmonary embolism. The causes of death were malignant disease (6 patients), cardiopulmonary disease other than pulmonary embolism (4 patients), and 'sudden' (2 patients). Though venous interruption surgery was not used, and long-term anticoagulation rare, the incidence of possible or probable recurrent embolism was low (6%). There was no definite evidence of persistence or subsequent development ofpulmonary hypertension after treatment in any patient. Resolution of embolism as judged by symptoms, signs, electrocardiogram, and chest x-ray examination was almost always complete. Some pulmonary arteriograms 1 to 6 months after initial treatment showed minor abnormalities, but others at a later date were normal. Perfusion lung scans carried out 1 to 8 years after initial treatment often showed minor abnormalities.The fate of patients with acute massive pulmonary embolism may be sudden death, deterioration over a matter of hours or days resulting in death, or complete recovery taking a varying period of time. It has been suggested that some patients initially presenting with acute pulmonary embolism may develop chronic pulmonary hypertension (Magidson and Jacobson, 1955;Wood, 1956;Phear, 1960). Speculation exists whether chronic thromboembolic pulmonary hypertension represents the end-result of unresolved massive pulmonary embolism or the long-term accumulation of repeated unresolved minor emboli (Dalen and Alpert, 1975)

Treatment of Acute Massive/Submassive Pulmonary Embolism.

“…The in-hospital mortality rate of this patient cohort was 28.6%, which accords with the high mortality rate (18-33%) reported by other investigators, [12][13][14] but is considerably higher than the 8% and 9.5% respective mortality rates of the hemodynamically stable patients included in the Urokinase in Pulmonary Embolism Trial 15 and the Prospective Investigation of Pulmonary Embolism Diagnosis trial. 16 Anticoagulation with heparin was initiated in all 35 patients in the present study and thomboembolytic agents were given to 30 (85.7%).…”

Long-term benefit of thrombolytic therapy in patients with pulmonary embolism

“…[12][13][14] The data presented in this report, however, show that post-embolic pulmonary hypertension in patients treated with conventional anticoagulation is not uncommon and that it can be prevented or minimized by initial treatment with thrombolytic agents. The latter, thus, appears to provide an early and sustained benefit for up to 7 years by effecting more complete clot resolution and by preserving the pulmonary vascular response to exercise in the long term.…”

High prevalence of dysfibrinogenemia among patients with chronic thromboembolic pulmonary hypertension

“…37 Long-term follow-up studies have consistently demonstrated that incomplete perfusion recovery, even years after acute PE, occurs in one-third to more than two-thirds of patients. [38][39][40][41] Up to 15% of acute PE patients remain symptomatically compromised 2 years after treatment 42 and may have abnormal pulmonary gas exchange (O 2 gradients, dead space, etc) as well. 43 These findings suggest that incomplete clot resolution has clinical manifestations in a significant proportion of acute PE patients, the most severe of which is CTEPH.…”