beth israel deaconess medical center echocardiography in pulmonary embolism gregory piazza, m.d....

Beth Israel Deaconess Medical CenterBeth Israel Deaconess Medical Center

Echocardiography in Pulmonary Echocardiography in Pulmonary EmbolismEmbolism

Gregory Piazza, M.D.Gregory Piazza, M.D.


January 26, 2005January 26, 2005


ObjectivesObjectives

• To present a brief overview of the To present a brief overview of the epidemiology, pathophysiology, epidemiology, pathophysiology, diagnosis, and management of acute diagnosis, and management of acute pulmonary embolism (PE).pulmonary embolism (PE).

• To review the role of echocardiography To review the role of echocardiography in the diagnosis of PE.in the diagnosis of PE.

• To highlight the role of To highlight the role of echocardiography in risk stratification of echocardiography in risk stratification of patients with PE.patients with PE.


EpidemiologyEpidemiology• The incidence of PE in the U.S. is The incidence of PE in the U.S. is

approximately 1 per 1000 per year.approximately 1 per 1000 per year.• Only 1 out of every 3 cases of venous Only 1 out of every 3 cases of venous

thromboembolism (VTE), including DVT thromboembolism (VTE), including DVT and PE, is diagnosed.and PE, is diagnosed.

• With approximately 450,000 cases With approximately 450,000 cases detected per year, a staggering 900,000 detected per year, a staggering 900,000 VTE cases may go undiagnosed VTE cases may go undiagnosed annually.annually.

Lancet 1999;353:1386-1389

Lancet 2004;363:1295-1305


EpidemiologyEpidemiology• In the Olmsted County registry, 30-day In the Olmsted County registry, 30-day

mortality after PE or DVT has been mortality after PE or DVT has been reported as high as 28%.reported as high as 28%.

• The International Cooperative The International Cooperative Pulmonary Embolism Registry Pulmonary Embolism Registry (ICOPER) estimates a 3-month (ICOPER) estimates a 3-month mortality of 17.4%.mortality of 17.4%.

• These data suggest PE is possibly as These data suggest PE is possibly as deadly as acute myocardial infarction.deadly as acute myocardial infarction.

Arch Intern Med 1999;159:445-453

Circulation 2003;108:2726-2729


PathophysiologyPathophysiology• The most common sources of PE are the The most common sources of PE are the

deep veins of the lower extremities and deep veins of the lower extremities and pelvis.pelvis.

• Thrombi dislodge from these veins and Thrombi dislodge from these veins and embolize to the pulmonary arterial tree where embolize to the pulmonary arterial tree where they trigger pathophysiologic changes in they trigger pathophysiologic changes in hemodynamics and gas exchange.hemodynamics and gas exchange.

• The size of the embolus, underlying The size of the embolus, underlying cardiopulmonary status, and neurohumoral cardiopulmonary status, and neurohumoral adaptations determine the hemodynamic adaptations determine the hemodynamic response to PE.response to PE.

Circulation 2003;108:2726-2729


PathophysiologyPathophysiology

www.benlovejoy.com/ pulmonary_embolism_main.html


PathophysiologyPathophysiology• Physical obstruction, release of vasoconstrictors, and Physical obstruction, release of vasoconstrictors, and

hypoxia lead to increased pulmonary vascular hypoxia lead to increased pulmonary vascular resistance (PVR) and right ventricular (RV) afterload.resistance (PVR) and right ventricular (RV) afterload.

• RV pressure overload leads to chamber dilatation RV pressure overload leads to chamber dilatation and hypokinesis, tricuspid regurgitation, and eventual and hypokinesis, tricuspid regurgitation, and eventual RV failure.RV failure.

• RV pressure overload also causes interventricular RV pressure overload also causes interventricular septal flattening during systole and deviation towards septal flattening during systole and deviation towards the left ventricle (LV) during diastole leading to the left ventricle (LV) during diastole leading to impaired LV filling.impaired LV filling.

• As RV pressure overload worsens, RV wall stress As RV pressure overload worsens, RV wall stress and ischemia develop secondary to increased and ischemia develop secondary to increased myocardial oxygen demand and decreased supply.myocardial oxygen demand and decreased supply.

Am Heart J 1995;130:1276-1282


PathophysiologyPathophysiology

↑ PA pressure↑ RV afterload

↑ RV wall tension

↑ RV O2 demand

RV dilatation and dysfunction

RV ischemia +/- infarction

↓ RV O2 supply

↓ coronary perfusion

Hypotension

↓ RV cardiac output

Septal shift toward the LV

↓ LV preload

↓ LV cardiac output

Pulmonary embolism

Am Heart J 1995;130:1276-1282


Spectrum of DiseaseSpectrum of Disease• A variety of clinical A variety of clinical

syndromes may be syndromes may be seen:seen:

1.1. Normotensive with Normotensive with normal RV functionnormal RV function

2.2. Normotensive with RV Normotensive with RV dysfunction dysfunction (submassive PE)(submassive PE)

3.3. Cardiogenic shock Cardiogenic shock (massive PE)(massive PE)

4.4. Cardiac arrest Cardiac arrest (massive PE)(massive PE)


Diagnosis: History and PhysicalDiagnosis: History and Physical

History:History:• Dyspnea (most Dyspnea (most

frequent symptom)frequent symptom)• Pleuritic chest painPleuritic chest pain• CoughCough• HemoptysisHemoptysis• SyncopeSyncope

Physical:Physical:• Tachypnea (most Tachypnea (most

frequent sign)frequent sign)• Anxious appearanceAnxious appearance• TachycardiaTachycardia• FeverFever• Elevated JVD (most Elevated JVD (most

specific sign)specific sign)• Loud P2Loud P2• Tricuspid regurgitationTricuspid regurgitation• Paradoxical bradycardiaParadoxical bradycardia


The Diagnostic ArmamentariumThe Diagnostic Armamentarium

• Arterial blood gasesArterial blood gases• ElectrocardiographyElectrocardiography• Chest X-rayChest X-ray• Plasma D-dimerPlasma D-dimer• Lower extremity Lower extremity

ultrasoundultrasound• Echocardiography Echocardiography

(TTE and TEE)(TTE and TEE)

• Ventilation-perfusion Ventilation-perfusion lung scanninglung scanning

• Spiral chest CTSpiral chest CT• Magnetic resonance Magnetic resonance

(MR) angiography(MR) angiography• Contrast pulmonary Contrast pulmonary

angiographyangiography


Diagnosis: An Integrated ApproachDiagnosis: An Integrated ApproachHistory and Physical

Eval. clinical likelihood

ElectrocardiogramChest radiograph

Patient already in hospital

Patient in ED

D-dimer

HighNormal

Chest CTV/Q if dye allergy or renal insufficiency

Normal Positive Equivocal Normal

Ultrasonography

Positive Negative

No PE Treat for PE Consider PA-gram

No PE

No PE

Lancet 2004;363:1295-1305


Diagnosis: Transthoracic Diagnosis: Transthoracic EchocardiographyEchocardiography

• Transthoracic echocardiography (TTE) is Transthoracic echocardiography (TTE) is insensitive in the diagnosis of acute PE.insensitive in the diagnosis of acute PE.

• In a prospective study, TTE failed to diagnose In a prospective study, TTE failed to diagnose 50% of patients with angiographically proven 50% of patients with angiographically proven PE.PE.

• However, in the appropriate clinical setting, However, in the appropriate clinical setting, findings of right ventricular pressure overload findings of right ventricular pressure overload may help suggest acute PE as a diagnosis.may help suggest acute PE as a diagnosis.

Lancet 2004;363:1295-1305

Am J Med 2001;110:528-535


Diagnosis: Transthoracic Diagnosis: Transthoracic EchocardiographyEchocardiography

Am J Respir Crit Care Med 2002;166:1310-1319

Apical 4- chamber Parasternal short-axis Parasternal long-axis


Echocardiographic Findings In Acute PEEchocardiographic Findings In Acute PE• RV dilatation and hypokinesisRV dilatation and hypokinesis• Interventricular septal flattening and paradoxical Interventricular septal flattening and paradoxical

motionmotion• Alteration of transmitral gradients with A wave > or = E Alteration of transmitral gradients with A wave > or = E

wavewave• Tricuspid regurgitation (TR) Tricuspid regurgitation (TR) • Pulmonary artery (PA) hypertension as estimated by Pulmonary artery (PA) hypertension as estimated by

the modified Bernoulli equationthe modified Bernoulli equation• RA dilatationRA dilatation• Loss of respiratory-phasic IVC collapse with inspirationLoss of respiratory-phasic IVC collapse with inspiration• Patent foramen ovalePatent foramen ovale• RA, RV, or pulmonary artery thrombusRA, RV, or pulmonary artery thrombus

Ann Intern Med 2002;136:691-700


RV DilatationRV Dilatation• In the apical 4 chamber In the apical 4 chamber

view, a ratio RVEDA view, a ratio RVEDA (area) to LVEDA > 0.6 (area) to LVEDA > 0.6 correlates with moderate correlates with moderate RV dilatation.RV dilatation.

• A ratio > or = 1.0 A ratio > or = 1.0 correlates with major RV correlates with major RV dilatation.dilatation.



RV HypokinesisRV Hypokinesis• RV hypokinesis is frequently diagnosed in a RV hypokinesis is frequently diagnosed in a

qualitative fashion.qualitative fashion.• Quantitative methods, such as RV fractional area Quantitative methods, such as RV fractional area

contraction, have not proven more accurate.contraction, have not proven more accurate.• McConnell et al. noted a specific qualitative finding in McConnell et al. noted a specific qualitative finding in

patients with RV dysfunction and acute PE compared patients with RV dysfunction and acute PE compared to patients with other causes of RV failure.to patients with other causes of RV failure.

• The McConnell sign is noted when RV free-wall The McConnell sign is noted when RV free-wall hypokinesis in observed in the setting of relatively hypokinesis in observed in the setting of relatively normal RV apical contraction.normal RV apical contraction.


Ann Intern Med 2002;136:691-700

Am J Cardiol 1996;78:469-473


RV HypokinesisRV Hypokinesis

Am J Cardiol 1996;78:469-473

• The RV free-wall endocardium was traced in the The RV free-wall endocardium was traced in the apical 4-chamber view from base to apex at end-apical 4-chamber view from base to apex at end-systole and end-diastole.systole and end-diastole.

• Tracings from patients with RV dysfunction from Tracings from patients with RV dysfunction from acute PE were compared to those with RV acute PE were compared to those with RV dysfunction from pulmonary arterial hypertension.dysfunction from pulmonary arterial hypertension.

• For PE, the McConnell sign had a sensitivity of 77%, For PE, the McConnell sign had a sensitivity of 77%, specificity of 94%, PPV of 71%, and NPV of 96%.specificity of 94%, PPV of 71%, and NPV of 96%.


RV HypokinesisRV Hypokinesis

Courtesy of A. Rosen


Interventricular septal flattening and Interventricular septal flattening and paradoxical motionparadoxical motion

• Right ventricular Right ventricular pressure overload leads pressure overload leads to deviation of the to deviation of the interventricular septum interventricular septum towards the LV in towards the LV in diastole.diastole.

• Interventricular septal Interventricular septal flattening is seen during flattening is seen during systole creating a so-systole creating a so-called D-shaped LV.called D-shaped LV.

Diastole

Systole


Ann Intern Med 2002;136:691-700

J Am Coll Cardiol 1987;10:1201-1206


Interventricular septal flattening and Interventricular septal flattening and paradoxical motionparadoxical motion


Normal (diastole) Acute PE (diastole)


Alteration of Transmitral GradientsAlteration of Transmitral Gradients

• In the setting of pericardial In the setting of pericardial constraint, interventricular constraint, interventricular septal motion towards the septal motion towards the LV during diastole leads to LV during diastole leads to impaired LV filling.impaired LV filling.

• Diastolic impairment leads Diastolic impairment leads to an A wave that is > or = to an A wave that is > or = to the E wave, signifying to the E wave, signifying increased dependence on increased dependence on atrial contraction for LV atrial contraction for LV filling.filling.

Normal

PE



Alteration of Transmitral GradientsAlteration of Transmitral Gradients



Tricuspid RegurgitationTricuspid Regurgitation• RV pressure overload RV pressure overload

frequently results in frequently results in tricuspid regurgitation tricuspid regurgitation detected on color flow detected on color flow and Doppler.and Doppler.

RV

RA LA

Ann Intern Med 2002;136:691-700

www.geocities.com/SouthBeach/ Cove/2045/echo55.htm


Pulmonary HypertensionPulmonary Hypertension• PA systolic pressure is PA systolic pressure is

estimated by using the estimated by using the modified Bernoulli modified Bernoulli equation:equation:

P = 4VP = 4V22

where P = peak pressure where P = peak pressure gradientgradient

V = peak velocity V = peak velocity of the TR jet of the TR jet

• Estimated RA pressure is Estimated RA pressure is added to the gradient to added to the gradient to approximate PA systolic approximate PA systolic pressure.pressure.


Ann Intern Med 2002;136:691-700



Thrombus In The Right Main PAThrombus In The Right Main PA

Ann Intern Med 2002;136:691-700


Diagnosis: Transesophageal Diagnosis: Transesophageal EchocardiographyEchocardiography

• Transesophageal echocardiography (TEE) Transesophageal echocardiography (TEE) can diagnose PE by direct visualization of the can diagnose PE by direct visualization of the proximal pulmonary arteries.proximal pulmonary arteries.

• Because the left main bronchus obstructs the Because the left main bronchus obstructs the view of the middle portion of the left view of the middle portion of the left pulmonary artery, PE is more difficult to pulmonary artery, PE is more difficult to detect in the left PA.detect in the left PA.

• TEE may play a unique role in the diagnosis TEE may play a unique role in the diagnosis of PE in patients with unexplained cardiac of PE in patients with unexplained cardiac arrest (especially pulseless electrical activity).arrest (especially pulseless electrical activity).

Ann Intern Med 2002;136:691-700



Long-axis transesophageal Short-axis transgastric Oblique transgastric




Ann Intern Med 2002;136:691-700


Case StudyCase Study• A 67 year old male with history of CAD, HTN, A 67 year old male with history of CAD, HTN,

and prostate cancer presents with acute and prostate cancer presents with acute onset dyspnea and dull chest pressure.onset dyspnea and dull chest pressure.

• On exam, he is tachycardic, tachypneic, On exam, he is tachycardic, tachypneic, hypoxic, but normotensive. He has elevated hypoxic, but normotensive. He has elevated neck veins and new lower extremity edema.neck veins and new lower extremity edema.

• His EKG reveals sinus tachycardia.His EKG reveals sinus tachycardia.• His chest X-ray is read as “no pneumonia, no His chest X-ray is read as “no pneumonia, no

CHF.”CHF.”• Because of high clinical suspicion for PE, he Because of high clinical suspicion for PE, he

undergoes chest CT.undergoes chest CT.


Case StudyCase Study


Case StudyCase Study• The patient is started on a weight-based The patient is started on a weight-based

protocol of intravenous unfractionated protocol of intravenous unfractionated heparin and admitted to a telemetry floor.heparin and admitted to a telemetry floor.

• That evening, the patient’s roommate calls That evening, the patient’s roommate calls the nurses station to report that the patient the nurses station to report that the patient has “slumped over in his chair.”has “slumped over in his chair.”

• The patient is found unresponsive and a code The patient is found unresponsive and a code is called.is called.

• The patient is found to be in pulseless The patient is found to be in pulseless electrical activity (PEA) and expires after electrical activity (PEA) and expires after resuscitative efforts are unsuccessful.resuscitative efforts are unsuccessful.


Risk StratificationRisk Stratification

Risk Stratification Tools:Risk Stratification Tools:• History and physicalHistory and physical• Clinical prognostic scoresClinical prognostic scores• Cardiac biomarkers including cardiac Cardiac biomarkers including cardiac

troponin and brain-type natriuretic troponin and brain-type natriuretic peptide (BNP)peptide (BNP)

• Chest CTChest CT• EchocardiographyEchocardiography


History and PhysicalHistory and Physical

• ICOPER reported ICOPER reported several independent several independent clinical predictors of clinical predictors of increased mortality increased mortality at 3 months.at 3 months.

Variable Hazard Ratio (95% CI)

Age > 70 years 1.6 (1.1-2.3)

Cancer 2.3 (1.5-3.5)

CHF 2.4 (1.5-3.7)

COPD 1.8 (1.2-2.7)

SBP <90 mmHg 2.9 (1.7-5.0)

Lancet 1999;353:1386-9


Cardiac BiomarkersCardiac Biomarkers• Cardiac troponins and BNP have been extensively Cardiac troponins and BNP have been extensively

studied in the evaluation of patients with acute PE. studied in the evaluation of patients with acute PE. • Cardiac troponins and BNP accurately identify low-Cardiac troponins and BNP accurately identify low-

risk PE patients with negative predictive values for in-risk PE patients with negative predictive values for in-hospital death ranging from 97 to 100%. hospital death ranging from 97 to 100%.

• Patients presenting with acute PE and elevated Patients presenting with acute PE and elevated cardiac biomarkers should undergo transthoracic cardiac biomarkers should undergo transthoracic echocardiography to assess RV function.echocardiography to assess RV function.

• In patients with acute PE and normal levels of cardiac In patients with acute PE and normal levels of cardiac biomarkers, echocardiography is not routinely biomarkers, echocardiography is not routinely required as RV function will most often be normal.required as RV function will most often be normal.

Circulation 2003;108:2191-2194


Cardiac BiomarkersCardiac BiomarkersReference n Biomarker Assay Cut-off level Test +,% NPV,% PPV,%

Konstantinides et al19 106 cTnI Centaur (Bayer) 0.07 ng/ml 41 98 14

Konstantinides et al19 106 cTnT Elecsys (Roche) 0.04 ng/ml 37 97 12

Giannitsis et al20 56 cTnT TropT (Roche) 0.10 ng/ml 32 97 44

Janata et al21 106 cTnT Elecsys (Roche) 0.09 ng/ml 11 99 34

Pruszczyk et al23 64 cTnT Elecsys (Roche) 0.01 ng/ml 50 100 25

ten Wolde et al27 110 BNP Shionoria (CIS Bio) 21.7 pmol/L 33 99 17

Kucher et al26 73 Pro-BNP Elecsys (Roche) 500 pg/ml 58 100 12

Kucher et al25 73 BNP Triage (Biosite) 50 pg/ml 58 100 12

Pruszczyk et al22 79 Pro-BNP Elecsys (Roche) 153-334 pg/ml* 66 100 23

*Age and gender adjusted cut-off levels according to manufacturer.Abbreviations: n, number; NPV, negative predictive value; PPV, positive predictive value; cTnI, cardiac troponin I; cTnT, cardiac troponin T; BNP, brain-type natriuretic

peptide; pro-BNP, pro-brain-type natriuretic peptide

Accuracy of cardiac biomarkers for the prediction of in-hospital death in acute pulmonary embolism.

Circulation 2003;108:2191-2194


Cardiac BiomarkersCardiac Biomarkers

↑ RV pressure

↑ PVR

RV micro-infarction

↑ RV shear stress

Myofibril degradation

↑ Natriuretic peptide mRNA

↑ Troponins ↑ BNP

Circulation 2003;108:2191-2194


Chest CT ScanChest CT Scan• Although chest CT is used primarily for the diagnosis Although chest CT is used primarily for the diagnosis

of PE, RV dilatation may also be observed.of PE, RV dilatation may also be observed.• In a study of 431 patients with acute PE diagnosed In a study of 431 patients with acute PE diagnosed

by chest CT, multiplanar reformats of axial CT data by chest CT, multiplanar reformats of axial CT data into CT 4-chamber views were performed.into CT 4-chamber views were performed.

• Right and left ventricular dimensions (RVRight and left ventricular dimensions (RVDD and LV and LVDD) ) were measured. RV enlargement was defined as were measured. RV enlargement was defined as RVRVD D /LV/LVDD > 0.9. > 0.9.

• RV enlargement predicted 30-day death (hazard RV enlargement predicted 30-day death (hazard ratio, 5.17, p = 0.005) after adjusting for pneumonia, ratio, 5.17, p = 0.005) after adjusting for pneumonia, cancer, chronic lung disease, and age.cancer, chronic lung disease, and age.

Circulation 2004;110:3276-3280


Chest CT ScanChest CT Scan

Circulation 2004;109:2401-2404


EchocardiographyEchocardiography• RV dysfunction on echocardiography has RV dysfunction on echocardiography has

been reliably established as a predictor of been reliably established as a predictor of adverse outcomes in PE.adverse outcomes in PE.

• The most commonly accepted quantitative The most commonly accepted quantitative standards are:standards are:1. RV to LV end-diastolic diameter ratio > 1 1. RV to LV end-diastolic diameter ratio > 1 in the apical 4-chamber view in the apical 4-chamber view2. RV end-diastolic diameter > 30 mm2. RV end-diastolic diameter > 30 mm3. Paradoxical interventricular septal 3. Paradoxical interventricular septal

systolic motion systolic motion

Ann Intern Med 2002;136:691-700


EchocardiographyEchocardiography• At the Karolinska Institute in Sweden, 126 At the Karolinska Institute in Sweden, 126

consecutive patients with PE were examined consecutive patients with PE were examined with TTE on the day of diagnosis.with TTE on the day of diagnosis.

• After multivariate analysis, RV dysfunction After multivariate analysis, RV dysfunction emerged as the most powerful predictor of in-emerged as the most powerful predictor of in-hospital death.hospital death.

• A 6-fold increase in relative risk was noted in A 6-fold increase in relative risk was noted in the patients with RV dysfunction compared to the patients with RV dysfunction compared to those with normal RV function.those with normal RV function.

Am Heart J 1997;134:479-487


EchocardiographyEchocardiography

• In a cohort of 209 consecutive patients with In a cohort of 209 consecutive patients with PE, 31% presented with a combination of PE, 31% presented with a combination of normal blood pressure and echocardiographic normal blood pressure and echocardiographic evidence of RV dysfunction. evidence of RV dysfunction.

• Of these patients, 10% developed cardiogenic Of these patients, 10% developed cardiogenic shock within 25 hours and 5% died in hospital. shock within 25 hours and 5% died in hospital.

• None of the patients with normal RV function None of the patients with normal RV function died from PE.died from PE.

Circulation 2000;101:2817-2822


EchocardiographyEchocardiography• In ICOPER, 90-day In ICOPER, 90-day

mortality rate was mortality rate was increased in patients increased in patients with RV dysfunction.with RV dysfunction.

• After multiple regression After multiple regression analysis, RV dysfunction analysis, RV dysfunction was found to be an was found to be an independent predictor of independent predictor of death at 90 days.death at 90 days.

Lancet 1999;353:1386-1389


Risk Stratification AlgorithmRisk Stratification AlgorithmNo shock Shock

BNP ↓Troponin ↓

BNP ↑Troponin ↑

RV dysfunctionNo RV dysfunction

Anticoagulation alone Consider thrombolysis or embolectomy

Echocardiography

Circulation 2003;108:2191-2194


ManagementManagement

Primary therapy:Primary therapy:• ThrombolysisThrombolysis• Open surgical Open surgical

embolectomyembolectomy• Catheter-assisted Catheter-assisted

embolectomyembolectomy

Secondary therapy:Secondary therapy:• IV unfractionated IV unfractionated

heparinheparin• Low-molecular weight Low-molecular weight

heparin (LMWH)heparin (LMWH)• FondaparinuxFondaparinux• WarfarinWarfarin• IVC filterIVC filter


ManagementManagement• In patients with massive PE, primary therapy with In patients with massive PE, primary therapy with

thrombolytics is considered a lifesaving intervention.thrombolytics is considered a lifesaving intervention.• Surgical or catheter-assisted embolectomy may be Surgical or catheter-assisted embolectomy may be

considered for massive PE if thrombolysis is considered for massive PE if thrombolysis is contraindicated.contraindicated.

• For submassive PE, thrombolysis remains For submassive PE, thrombolysis remains controversial as no mortality benefit has been shown controversial as no mortality benefit has been shown in this patient population.in this patient population.

• However, MAPPET-3 demonstrated a reduction in However, MAPPET-3 demonstrated a reduction in need for escalation of therapy in patients receiving need for escalation of therapy in patients receiving up-front t-PA (alteplase) for submassive PE.up-front t-PA (alteplase) for submassive PE.

• Normotensive patients with normal RV function are Normotensive patients with normal RV function are considered low-risk and receive standard considered low-risk and receive standard anticoagulation.anticoagulation.

J Thromb Thrombolysis 1995;2:227-229

N Engl J Med 2002;347:1143-1150


Thrombolysis in PE: Pre-LyticsThrombolysis in PE: Pre-Lytics

*Following echo loops are courtesy of A. Kothavale


Thrombolysis in PE: Post-LyticsThrombolysis in PE: Post-Lytics


ConclusionsConclusions

• Pulmonary embolism is a common and Pulmonary embolism is a common and potentially life-threatening disorder.potentially life-threatening disorder.

• Echocardiography is insensitive in the Echocardiography is insensitive in the diagnosis of acute PE.diagnosis of acute PE.

• In conjunction with cardiac biomarkers, In conjunction with cardiac biomarkers, echocardiography plays a important role echocardiography plays a important role in risk stratification of patient with PE.in risk stratification of patient with PE.


The End…The End…

beth israel deaconess medical center echocardiography in pulmonary embolism gregory piazza, m.d....

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