Pulmonary Embolism: Presentation, Natural History, and Treatment

Acute pulmonary embolism (PE) is a leading cause of cardiovascular mortality. Clinical presentation varies from asymptomatic to fatal; symptoms depend on the embolic burden and the severity of any underlying cardiopulmonary disease. While in the majority pulmonary thrombo-emboli will gradually resolve, in some patients it may organize into fibrotic deposits permanently occluding the pulmonary arteries leading to chronic thromboembolic pulmonary hypertension (CTPH). Computed tomographic pulmonary arteriography (CTPA) is the method of choice for imaging the pulmonary vasculature in patients with suspected PE and transthoracic echocardiography (TTE) is the most common first-line examination to diagnose the signs of right ventricular dysfunction. The main goal of therapy is to prevent mortality; a secondary goal, recently suggested, is the potential prevention of late-onset CTPH PE sequelae to improve quality of life. Systemic anticoagulation is the standard of care and treatment can be escalated in the setting of high or intermediate risk PE. Advanced treatment options include systemic thrombolysis, catheter-directed interventions and surgical thromboembolectomy. Patient selection criteria, hemodynamic and clinical outcomes continue to be defined to determine the indications and benefits of invasive interventions.