State-of-the-Art Review
Echocardiographic Evaluation of Pulmonary Embolism: A Review

https://doi.org/10.1016/j.echo.2023.05.006Get rights and content

Highlights

  • Intermediate- to high-risk PE patients pose a therapeutic challenge.

  • Echocardiographic findings have prognostic value in the management of PE.

  • Every parameter has its own set of limitations.

Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States. Appropriate risk stratification is an important component of the initial evaluation for acute management of these patients. Echocardiography plays a crucial role in the risk stratification of patients with PE. In this literature review, we describe the current strategies in risk stratification of patients with PE using echocardiography and the role of echocardiography in the diagnosis of PE.

Introduction

Venous thromboembolism (VTE) represents a major cause of morbidity and mortality, with an incidence of approximately 900,000 cases annually in the United States.1 After myocardial infarction and stroke, pulmonary embolism (PE) forms the third most common cause of cardiovascular death.2 Pulmonary embolism has an estimated incidence of 117 cases per 100,000 people in the United States, although the incidence rate is likely underestimated given the high likelihood of silent PEs in patients with deep vein thrombosis (DVT).3,4

Even though there are approximately 60,000 to 300,000 deaths attributed to PE, most of which occur in inpatients, historical trends have indicated that PE-related mortality has been decreasing.5,6 Pulmonary embolism is an independent predictor of death for up to 3 months after the event, and the risk is 18-fold higher when compared to patients with only DVT.7

The diagnosis and management of PE is based on a combined picture of pretest probability, D-dimer levels, electrocardiogram, computed tomography (CT) pulmonary angiography (CT-PA), and transthoracic echocardiography (TTE). Risk stratification for this disease process relies significantly upon accurate assessment of right ventricular (RV) function, which is a powerful predictor of cardiopulmonary morbidity and mortality.8 In this literature review, we describe the current strategies for risk stratification and echocardiographic evaluation of PE. Echocardiographic assessment of PE includes the following components: RV size, McConnell’s sign, the 60/60 sign, RV systolic function including tricuspid annular planar systolic excursion (TAPSE), RV fractional area change (FAC), TAPSE/pulmonary artery systolic pressure (PASP) ratio, left ventricular outflow tract (LVOT) velocity-time integral (VTI), RV outflow tract (RVOT) VTI, PASP/left ventricular stroke volume (LVSV), and visualization of thrombus in transit.

Section snippets

Pretest Probability and Imaging

Computed tomography pulmonary angiography is the mainstay for the definitive diagnosis of PE. The decision to pursue CT-PA is based on pretest probability. The Wells score calculates a pretest probability for PE, and a score of greater than 4 is a recommendation for such imaging.9 The Wells score consists of 7 criteria, one of which is “pulmonary embolism is the most likely diagnosis,” with a weight of 3 points. As the Wells score has been criticized for being subjective due to this criterion,

Risk Stratification

Based on PE severity and the risk of in-hospital and 30-day mortality, the European Society of Cardiology (ESC) classifies PE into 4 categories–low risk, intermediate-low, intermediate-high, and high risk.12 The American Heart Association has classified the severity of PE into low risk, submassive, and massive PE, the difference being that both of the intermediate-risk groups are grouped together to be called submassive PE.13

High-risk PE is defined as patients with hemodynamic instability

Conclusion

The management of intermediate-risk PE remains a constantly evolving topic and often requires a multidisciplinary approach. Echocardiographic findings can help determine which subset of intermediate-risk PEs need therapies beyond anticoagulation. These parameters should be used in conjunction with the clinical picture and pretest probability of the patient to make the decision on the next best management intervention.

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  • Conflicts of Interest: None.

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