What is a pulmonary embolism causes around 15,000 deaths per year. Elderly people are most affected by this cardiovascular disease, the symptoms of which often appear suddenly. If treatment is started in time, it is possible to recover and, in most cases, return to normal life.
What is a pulmonary embolism?
Pulmonary embolism (PE) is the occlusion of one or more pulmonary arteries , most often due to a blood clot that has migrated from the lower limbs.
A Pulmonary embolism can damage the lungs. If not dissolved or reduced, the thrombus disrupts blood circulation and gas exchange in the lungs.
The result is a lack of oxygen supply to the lung, which risks leading to the death of tissues in this essential organ. We then speak of a Pulmonary embolism infarction.
PE causes insufficient oxygenation of other vital organs and thus can lead to death.
Massive pulmonary embolism
When the obstruction exceeds 50% of the diameter of the pulmonary artery, it is called massive pulmonary embolism.
This causes acute cardiopulmonary failure. This is a medical emergency that can lead to death, particularly from cardiac arrest, if not treated quickly. This condition is aggravated by existing pathologies in the patient.
About 70% of patients who die from a pulmonary embolism die within the first hour after symptoms appear. Rapid assessment and intervention are therefore necessary.
Pulmonary embolism in figures in United States
How does pulmonary embolism occur?
Pulmonary embolism occurs when a substance (called an emboli) becomes blocked in the arteries of the lungs, preventing blood from passing through the vessels.
Deep vein thrombosis (DVT)
Pulmonary embolism is usually a complication of deep vein thrombosis (DVT).
Also called phlebitis, DVT is an event in which a blood clot (thrombus) forms within a blood vessel in the body. The thrombus generally forms in the veins of the lower limbs :
- leg,
- thigh,
- groin fold.
Sometimes the blood clot breaks up and travels with the bloodstream toward the heart . When it contracts, the right ventricle can propel the clot (now called an embolus) into an artery in the lungs. There, the clot can get stuck in a smaller vessel and thus block the blood supply to the lung (this is called hypoxemia).
What are the other types of emboli?
Pulmonary embolism is not always caused by a blood clot . Other substances can cause blocked blood vessels and travel into the lungs.
The main emboli (substances causing embolism) are:
- A blood clot (most common case);
- Amniotic fluid (amniotic embolism), during childbirth;
- Tumor cells in the case of cancer;
- The bone marrow (fat embolism), after a fracture,
- Bacteria (septic embolism), during an infection, etc.
What is the cause of pulmonary embolism?
Known causes of pulmonary embolism include:
- The accumulation of blood in a part of the body (usually an arm or leg). This usually occurs after long periods of inactivity, such as surgery with immobilization or a long plane trip.
- Injury to a vein, due to fracture or surgery (especially in the pelvis, hip, knee or leg).
- Another medical problem, including various cardiovascular diseases :
- congestive heart failure ,
- atrial fibrillation (heart rhythm disorder),
- myocardial infarction (heart attack),
- cerebrovascular accident (CVA).
- A disruption of blood clotting factors. An increase in clotting factors can be caused by certain cancers, hormone replacement therapy or birth control pills. Blood clotting disorders can also cause a decrease or dysregulation of clotting factors.
These different conditions promote the formation of clots in the blood vessels, which can cause a pulmonary embolism.
What are the risk factors for pulmonary embolism?
The risks of developing a pulmonary embolism are increased by the following factors:
- Long period of inactivity : long-haul plane travel, bed rest following an operation, etc.
- Fracture or surgery (especially arthroplasty to replace certain joints, such as the hip, and other orthopedic operations),
- History of deep vein thrombosis (DVT) or previous pulmonary embolism,
- Disorders affecting coagulation : certain hereditary diseases (thrombophilia) and various pathologies, including certain kidney diseases.
- High blood pressure,
- Chronic obstructive pulmonary disease (COPD),
- Inflammation of the intestine and cardiovascular diseases (see above),
- Certain cancers — especially colon , brain, ovarian, pancreatic, stomach, lung, and kidney cancers, and those that have spread throughout the body. Chemotherapy also increases the risk. A personal or family history of breast cancer, associated with taking tamoxifen (hormonotherapy) or raloxifene (Evista – against osteoporosis), increases the risk of thrombus.
- Covid-19 ,
- Central venous catheter in the arm or leg,
- Oral contraceptives and hormone replacement therapy . The estrogen in these medications may increase clotting factors in the blood, especially in smokers and people who are overweight.
- Smoking (especially associated with other risk factors),
- Overweight (body mass index [BMI] greater than 25) and obesity (BMI greater than 30),
- Pregnancy or childbirth within the previous six weeks . The weight of a baby pressing on the veins in the pelvis can slow the return of blood from the legs to the heart,
- Age . The risk increases with age, especially after 40 years.
What are the symptoms of pulmonary embolism?
In almost half of the cases, the pulmonary embolism is discreet and the patients hardly show any symptoms.
Symptoms of pulmonary embolism include:
- sudden or new shortness of breath : dyspnea is often the first sign of pulmonary embolism. It is due to the reduction in the quantity of oxygen that can be transported into the blood;
- breathing ; rapid , short
- chest pain on one side or below the breastbone. It gets worse with deep breaths (unlike the pain of a heart attack which is constant). The pain is sharp, like a knife being plunged into the ribcage,
- anxiety,
- coughing and sometimes spitting up blood.
The following signs of shock indicate the presence of a serious pulmonary embolism:
- fast heartbeat (tachycardia);
- arterial hypotension;
- dizziness or loss of consciousness;
- clammy skin, excessive sweating;
- blue lips and skin.
How is pulmonary embolism diagnosed?
The diagnosis of pulmonary embolism is usually made in the hospital . The symptoms experienced lead to rapid referral to the emergency department of a hospital center.
The medical team generally begins with blood tests to detect certain markers of pulmonary embolism and possibly heart damage:
- D-dimer dosage : they indicate the presence of a clot. A low level can rule out the diagnosis of pulmonary embolism. A high rate does not necessarily confirm this,
- troponin levels : its increase, generally reflecting a heart disorder, is also often observed in cases of pulmonary embolism,
The doctor also asks the patient about their symptoms and risk factors .
Various examinations are carried out:
- arterial blood gas analysis , to measure oxygen, carbon dioxide and other gases in the blood,
- electrocardiogram (ECG), to record the electrical activity of the heart
- echocardiography (cardiac Doppler echo): use of ultrasound to obtain images of the heart,
- thoracic angioscan (lung scan): it allows you to visualize the blood clot in the lungs, to locate it and estimate its impact on the heart,
- perfusion/ventilation lung scintigraphy : scan using a radioactive substance to find all areas of the lungs where the circulation of oxygen and blood is disrupted by a blood clot,
- Doppler ultrasound of the veins of the lower limbs : to look for possible phlebitis.
In pregnant women, magnetic resonance imaging (MRI) can replace computed tomography (CT).
What is the treatment for pulmonary embolism?
pulmonary embolism requires immediate medical treatment. The goal: to dissolve clots and prevent new thrombi from forming. Treatment options include medications and surgical procedures.
Drug treatments
- Anticoagulant treatment is the first to be implemented. It prevents the extension of clots and prevents the formation of new thrombi.
- It usually starts as intravenous or subcutaneous injections of heparin or fondaparinux – for five to nine days.
- It is supplemented by oral treatment (tablets), such as vitamin K antagonists (AVK) or direct oral anticoagulants (DOACs). Oral anticoagulant treatment generally continues for 3 to 6 months. In certain cases, it will be taken for life (in particular, when the exact cause of the pulmonary embolism could not be determined).
- Anticoagulants can cause bleeding , especially if the patient is taking other medications that also thin the blood, such as aspirin.
- Thrombolysis – This involves the intravenous injection of thrombolytic drugs to dissolve blood clots quickly. It is prescribed in cases of large clots causing serious symptoms or other severe complications (shock and risk of cardiac arrest). Thrombolytics can cause sudden bleeding, so they are used for massive or severe life-threatening pulmonary embolism.
Surgical interventions
In cases of severe pulmonary embolism and when the thrombus cannot be dissolved with medication, there are different surgical procedures:
- Embolectomy : The clot is removed as part of a surgical procedure.
- Thrombectomy by catheter-guided thrombus aspiration (flexible tube to reach the blood clot in the lung).
- Catheter thrombolytic therapy : this allows part of the systemic thrombolysis to be administered directly into the clot inside the lungs.
- Cellar filter : used in some people who cannot receive anticoagulants. A filter is inserted into a large vein called the inferior vena cava. It stops blood clots before they travel to the lungs, preventing pulmonary embolism. But the filter does not prevent new blood clots from forming.
Care in a retirement home
Pulmonary embolism can leave after-effects, especially in elderly people already suffering from several pathologies . In the event of heart failure, for example, the patient can lose his autonomy. Staying at home may then prove difficult, as the senior encounters difficulty in carrying out essential tasks (cleaning, washing, etc.).
A reception in a nursing home (EHPAD) allows daily care of the resident . In addition, the nursing staff at the residence will ensure that he follows his anticoagulant treatment.
How do you die from a pulmonary embolism?
When pulmonary embolism is diagnosed in time and the patient receives appropriate treatment, it is rarely fatal.
Untreated, the disease can be serious and lead to other medical complications, including death.
About a third of patients die before receiving a diagnosis and treatment.
With a large thrombus blocking the passage, the right ventricle of the heart exerts excessive effort to eject blood into the arteries of the lungs. This pressure on the heart can cause heart failure.
When oxygen can no longer pass into the blood, hypoxemia can also lead to cardiac arrest. The risk is increased in the event of massive pulmonary embolism. In this case, the treatment must be very rapid.
What is the life expectancy after a pulmonary embolism?
Life expectancy after a pulmonary embolism is influenced by various elements, including:
- extent of the embolism,
- possible pre-existing pathologies,
- age and overall health of the patient,
- speed with which the diagnosis was made,
- treatment implemented.
The 1-year mortality rate is 16% among patients aged 75 and over (Faure and Boucif, 2019)
Nearly 85% of patients (all ages) who survive a severe pulmonary embolism are still alive 10 years after the event, according to research published in the journal Thrombosis Research . Most of these individuals also manage to return to their usual daily routine.
However, some people may suffer long-term aftereffects after a pulmonary embolism, including:
- pulmonary hypertension , which is characterized by high blood pressure in the lungs,
- post-thrombotic syndrome , leading to pain, swelling and a feeling of heaviness in the legs.
How to prevent a pulmonary embolism?
Prevention of pulmonary embolism involves reducing the risk factors mentioned above:
- Participate in a sporting activity or exercise regularly.
- Try to quit smoking.
- Lose weight in case of obesity.
- Respect anticoagulant treatment, for people who receive one.
- Wear compression stockings to encourage blood circulation when it is necessary to remain still for long periods.
- Drink plenty of fluids, but limit alcohol and caffeine.
- Avoid crossing your legs.
- Do not wear tight clothing.
- Raise your feet for 30 minutes twice a day.
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