IM Board Review

A 75-year-old with abdominal pain, hypoxia, and weak pulses in the left leg

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References

Duplex ultrasonography can show evidence of deep vein thrombosis if a venous segment is not compressible ( Figure 3 ). Of note, approximately 70% of patients with pulmonary embolism have evidence of deep vein thrombosis on imaging studies. 4

Venous duplex ultrasonography has become the standard for diagnosis of lower extremity deep vein thrombosis. However, its quality and diagnostic accuracy depend on the skill of the person performing the examination. It is further limited by certain patient characteristics, including severe obesity, edema, and wounds and dressings at the site being examined. 5

Our patient underwent duplex ultrasonography of the lower extremities, which demonstrated acute proximal and calf deep vein thrombosis in the right femoral, popliteal, and peroneal veins and no deep vein thrombosis in the left leg.

RISK STRATIFICATION IN ACUTE PULMONARY EMBOLISM

Multiple models exist to estimate the risk of complications in patients with acute pulmonary embolism.

The Bova score 6 is based on the following factors:

  • Systolic blood pressure 90–100 mm Hg (2 points) (patients with systolic blood pressure lower than 90 mm Hg were excluded from the study from which this score was derived)
  • Cardiac troponin elevation (2 points)
  • Right ventricular dysfunction on echocardiography or computed tomography (2 points)
  • Heart rate 100 beats/min or greater (1 point).

A total score of 0, 1, or 2 (stage I) denotes low risk, 3 or 4 points (stage II) intermediate risk, and more than 4 points (stage III) high risk.

The PESI score (Pulmonary Embolism Severity Index) 7 is based on:

  • Age (1 point per year)
  • Sex (10 points for being male)
  • Heart rate 110 per minute or greater (20 points)
  • Cancer (30 points)
  • Heart failure (10 points)
  • Chronic lung disease (10 points)
  • Systolic blood pressure less than 100 mm Hg (30 points)
  • Respiratory rate at least 30 per minute (20 points)
  • Temperature less than 36ºC (20 points)
  • Altered mental status (60 points)
  • Arterial oxygen saturation less than 90% (20 points).

The total score is broken down into 5 classes: I (< 65 points), II (65–85), III (86–105), IV (106–125), and V (> 126). Classes I and II are low risk, and the higher ones are high risk.

The simplified PESI score 8 was developed to more rapidly risk-stratify patients and has been found to be similar to the PESI score in prognostic accuracy. Patients get 1 point for each of the following:

  • Age over 80
  • Cancer
  • Chronic cardiopulmonary disease (heart failure or chronic lung disease)
  • Heart rate 110 per minute or greater
  • Systolic blood pressure less than 100 mm Hg
  • Arterial oxygen saturation less than 90%.

A total score of 0 is low risk; anything higher is high risk.

Back to our patient

Our patient had proximal and calf deep vein thrombosis of the right leg, bilateral submassive pulmonary emboli with associated biomarker elevation and right ventricular dysfunction, and left renal artery thrombosis with infarction. Using the PESI score, his risk of death in the next 30 days was 13.7% and his 30-day risk of a complicated course was 27%. Using the Bova score, his 30-day risk of death was 15.5% and his 30-day risk of a complicated course was 29.2%. 6,7

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