Pulmonary embolism in hospital practice

Editor—Robinson says that diagnosis of pulmonary embolism can be difficult but does not mention the available scoring systems that are useful in defining the likelihood of pulmonary thromboembolism.¹,² Most importantly, she makes no mention of biomarkers and does not emphasise the critical importance of echocardiography or computed tomography scanning to identify right ventricular strain.

Figure 1.

Patients with a raised troponin concentration (I or T) and echo or computed tomographic evidence of right ventricular overload have 10 times the risk of death or major adverse event than individuals with a normal troponin value and normal right ventricular function.³,⁴

Importantly, the recommendation of low molecular weight heparin as initial treatment for all applies only to stable patients. Patients with shock should receive intravenous heparin, since cutaneous perfusion is compromised, and low molecular weight heparin may not be absorbed.

Finally, Robinson makes no mention of life saving surgical embolectomy or percutaneous fragmentation procedures, which have a key role in a gravely ill patients with massive pulmonary embolism.²,⁵

Modern management of patients with pulmonary embolism demands three investigations: an immediate troponin measurement, computed tomographic pulmonary angiography, and definition of involvement of the right ventricle by computed tomography or echocardiography. Without these we will remain stuck in 1990s medicine.