Embolia pulmonar
Summary
Definition
History and exam
Key diagnostic factors
- dispneia
- dor torácica
- sinais de trombose venosa profunda (TVP) concomitante
- fatores de risco
- hipoxemia
- falha em atender aos critérios de descarte de embolia pulmonar (a regra CDEP)
- pontuação de Wells (ou Genebra) positiva
- sinais de instabilidade hemodinâmica ou reserva hemodinâmica severamente reduzida
Other diagnostic factors
- tosse
- febre
- hemoptise
Risk factors
- idade mais avançada
- diagnóstico de trombose venosa profunda (TVP)
- obesidade (IMC ≥29 kg/m²)
- cirurgia nos 2 meses anteriores
- repouso total no leito >5 dias
- evento tromboembólico venoso prévio
- histórico familiar de tromboembolismo venoso
- neoplasia ativa
- tabagismo
- doença pulmonar obstrutiva crônica (DPOC)
- trauma ou fratura recente
- insuficiência cardíaca congestiva (ICC)
- cateterização venosa central
- gestação/período pós-parto
- veias varicosas
- viagem de longa duração recente
- história de aborto espontâneo
- infarto agudo do miocárdio recente
- sepse
- transfusão sanguínea recente
- contracepção hormonal combinada
- terapia de reposição hormonal (TRH) oral
- paralisia dos membros inferiores
- doença inflamatória intestinal
- síndrome nefrótica
- Doença de Behçet
- homocisteinemia
- neoplasia mieloproliferativa negativa para Filadélfia
- mutação do fator V de Leiden
- Mutação no gene G20210A da protrombina
- deficiência de antitrombina
- deficiência de proteína C
- deficiência de proteína S
- síndrome do anticorpo antifosfolipídeo
Diagnostic tests
1st tests to order
- Angiografia pulmonar por tomografia computadorizada (APTC)
- ecocardiografia
- dímero D
- hemograma completo
- eletrocardiograma (ECG)
- ureia e eletrólitos
- exames de coagulação
- testes da função hepática
Tests to consider
- gasometria arterial
- radiografia torácica
- ultrassonografia venosa de compressão de membros inferiores
- biomarcador cardíaco
- cintilografia de ventilação/perfusão (V/Q)
- investigação adicional por EP não provocada
Emerging tests
- biomarcadores
- teste de dímero D no local de atendimento
- Dímero D ajustado à probabilidade clínica
- angiografia por ressonância magnética (ARM)
Treatment algorithm
Suspeita de EP: hemodinamicamente instável E/OU hipoxêmico
EP confirmada (à ecocardiografia ou APTC); hemodinamicamente instável
EP confirmada (à APTC) ou altamente suspeitada (Wells >4 ou dímero D positivo); hemodinamicamente estável
primeiro episódio de EP confirmado (iniciada anticoagulação de fase aguda)
EP recorrente apesar de uma terapia anticoagulante adequada
Contributors
Expert advisers
Jonathan Bennett, MD
Honorary Professor of Respiratory Sciences
University of Leicester
Respiratory Consultant
Glenfield Hospital
Leicester
UK
Biography
JB is deputy medical director RCP Invited Service Reviews, and speaker at National Society (eg., BTS), Primary Care Respiratory Society, and Society Cardiothoracic Surgeons meetings.
Disclosures
JB declares that he has no competing interests.
Richard Russell, MBBS, PhD, MRCP
Specialty Registrar in Respiratory Medicine
Glenfield Hospital
Leicester
UK
Disclosures
RR received sponsorship from AstraZeneca to attend a conference, May 2018 (covering travel, accommodation, and conference fee).
Onyeka Umerah
Consultant Respiratory Physician
Glenfield Hospital
Leicester
UK
Disclosures
OU declares that she has no competing interests.
Claire Vella
Consultant Respiratory Physician
Glenfield Hospital
Leicester
UK
Disclosures
CV declares that she has no competing interests.
Acknowledgements
BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:
Scott M. Stevens MD
Director
Thrombosis Clinic
Intermountain Medical Center
Murray
UT
Professor of Medicine
Department of Internal Medicine
University of Utah
Salt Lake City
UT
Scott C. Woller MD
Director
Thrombosis Clinic
Intermountain Medical Center
Murray
UT
Professor of Medicine
University of Utah
Salt Lake City
UT
Gabriel V. Fontaine PharmD, BCPS
Clinical Coordinator
Critical Care Pharmacy
Advanced Clinical Pharmacist
Neuroscience Critical Care
Intermountain Medical Center
Murray
UT
Disclosures
SMS is an investigator for two investigator-initiated clinical trials for which his institution receives funds from Bristol-Myers Squibb to enrol patients. SCW holds two investigator-initiated grants from Bristol-Myers Squibb/Pfizer paid to his employer Intermountain Healthcare for which he receives no compensation. He has been invited to serve as co-chair of the American College of Chest Physicians guideline on antithrombotic therapy for venous thromboembolic disease (AT11) and serves as an invited panelist for the US Centers for Disease Control and Prevention venous thromboembolism risk assessment model systematic review and guidance panel. GVF receives consulting fees and honoraria from Portola Pharmaceuticals for clinical consulting and speaking engagements.
Peer reviewers
Catherine Free
Consultant Respiratory Physician
Medical Director
George Eliot Hospital NHS Trust
Nuneaton
UK
Disclosures
CF declares that she has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020 Jan 21;41(4):543-603.Full text Abstract
National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. Aug 2023 [internet publication].Full text
Howard LSGE, Barden S, Condliffe R, et al. British Thoracic Society guideline for the initial outpatient management of pulmonary embolism (PE). Thorax. 2018 Jul;73 (Suppl 2):ii1-29.Full text Abstract
Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic therapy for VTE disease: second update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160(6):e545-608.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Angina instável
- Infarto do miocárdio sem supradesnivelamento do segmento ST (IAMSSST)
- Infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST)
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- Venous thromboembolic diseases: diagnosis, management and thrombophilia testing
- 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism
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