Pulmonary embolism in the elderly: a review on clinical, instrumental and laboratory presentation

Figures & data

Table 1 Main clinical aspects of elderly patients with PE

Reference Year	Busby 1988	Stein 1991	Gisselbrecht 1996	Ramos 2000	Masotti 2003	Ceccarelli 2003	Timmons 2003	Punukollu 2005	Koktur 2005	Le Gal 2005	Tot./Range (1988–2005)
Type of study	R	P	P	R	R	R	R	P	R	P
Diagnostic	V/Q scan		V/Q scan/	Q scan/	V/Q scan/	Q scan	Q scan	hCT	V/Q scan/	V/Q scan	hCT
Method		pulmonary angiography	pulmonary angiography	pulmonary angiography				hCT
Patient Number	37	72	26	64	68	59	29	70	58	167	650
Male/female	17/20	32/40	10/16	24/40	22/46	18/41	12/17	29/41	21/37	61/106	246/404
Mean Age(years ± SD)	76	≥70	80 ± 3	69 ± 17	78.6 ± 7.7	81.9 ± 5.2	74.7	76.4 ± 8.37	72.7 ± 6.1	≥75	(65–99)
Mortality	21.6%	nr	11.5%	8%	29.5%	32%	nr	17%	nr	nr	(8%–32%)
Symptoms and signs
Dyspnea	65%	78%	85%	66%	88%	91.5%	59%	74%	84.5%	81.9%	(59–91.5%)
Tachycardia	nr	29%	nr§	nr*	74%	67%	31%	44%	nr	32.9%	(29–76%)
Chest pain	57%	51%	35%	27%	40%	39%	59%	26%	48.3%	46.1%	(26–57%)
Tachypnea	46%	74%	nr	nr	50%	47%	nr	nr	nr	73.1%	(46–74%)
Syncope	8%	nr	62%	11%	13.5%	20%	nr	19%	27.6%	18.6%	(8–62%)
Shock	5%	10%	31%	nr	13.5%	18%	24%	nr	nr	nr	(5–31%)
Cough	43%	35%	nr	12%	22%	20%	24%	nr	16%	nr	(12–43%)
Hemoptysis	11%	8%	0%	3%	nr	nr	14%	nr	6.9%	4.8%	(3–14%)
Risk factors
Bed rest	25%	67%	15%	45%	65%	54%	nr	21%	40%	nr	(15%–67%)
DVT	16%	15%	50%	47%	35%	34%	16%	19%	44.8%	nr	(15%–50%)
Cancer	32%	26%	4%	20%	16.5%	18.5%	nr	30%	13.8%	9.0%	(4%–32%)
Surgery	22%	44%	19%	14%	7%	5%	nr	9%	26%	6.6%	(5%–44%)
Heart failure	30%	nr	nr	33%	25%	32%	nr	nr	5%	15%	(5%–33%)
Previous DVT/PE	27%	nr	19%	18%	24%	23.5%	nr	19%	35%	41%	(18%–41%)
Stroke	11%	nr	nr	nr	13.5%	12%	nr	nr	nr	3%	(3%–13.5%)
AMI	11%	nr	nr	nr	nr	3%	nr	nr	nr	nr	(3%–11%)
COPD	nr	nr	nr	nr	13.5%	27%	nr	nr	2%	8.4%	(2%–27%)

Abbreviations:DVT, deep vein thrombosis; AMI, Acute myocardial infarction; COPD, chronic obstructive pulmonary disease; nr, not reported;

* Mean heart rate 95 ± 17 beats for minute;

§ mean heart rate 100 ± 16 beats for minute;

°Right ventricular failure 46%; the study of Gisselbrecht¹⁵ was referred to massive pulmonary embolism. V, ventilation; Q, perfusion; hCT, helical computer tomography. R, retrospective; P, prospective.

Table 2 12-leads electrocardiography, chest X-ray, arterial blood gas analysis findings 12-leads ECG

Reference Year	Stein 1991	Ramos 2000	Masotti 2003	Ceccarelli 2003	Timmons 2003	Kokturk 2005	Tot./Range (1988–2005)
Normal	21%	nr	nr	nr	nr	50%	(21%–50%)
Sinus tachycardia	nr	nr	60%	62.5%	18%	nr	(18%–62.5%)
Atrial fibrillation	nr	20%	20%	20.5%	7%	13.6%	(7%–20.5%)
RBBB	9%	9%	27%	40.5%	18%	4.5%	(4.5%–40.5%)
S1Q3/S1Q3T3T3	nr	8%	12%	8.5%	14%	4.5%	(4.5%–14%)
ST-T abnormalities	56%	22%	34%	51%	4%	13.6%	(4%–56%)
Chest X-ray
Reference Year	Busby 1988	Stein 1991	Ramos 2000	Masotti 2003	Ceccarelli 2003	Le Gal 2005	Tot./Range (1988–2005)
Abnormal	38%	96%	43%	80.5%	86.5%	nr	(38%–96%)
Cardiomegaly	nr	22%	20%	58%	64%	nr	(22%–64%)
Pulmonary edema	nr	13%	nr	13.5%	30.5%	nr	(13%–30.5%)
Pleural effusion	16%	57%	nr	18%	17%	15.8%	(15.8%–57%)
Atelectasis	22%	71%	14%	15%	8.5%	14%	(8.5%–71%)
Hemidiaphragm elevation	nr	28%	nr	nr	8.5%	18.2%	(8.5%–28%)
ABG
Reference Year	Stein 1991	Jones et al 1993	Gisselbrecht 1996	Ramos 2000	Masotti 2003	Ceccarelli et al 2003	Kokturk et al 2005	Tot./Range (1988–2005)
Mean paO2(mmHg)	61 ± 12	61.4	55 ± 9	60 ± 10	54.6 ± 14.7	53.5 ± 15.4	59.5 ± 9.8	(53.5–61.4)
Mean paCO2(mmHg)	nr	nr	30 ± 5	33 ± 5	41.7 ± 15	42.1 ± 16.5	32.9 ± 9.8	(30–42.1)
Mean [D(A-a)O2] (mmHg)	nr	46.6	nr	nr	45.3 ± 22.4	44.8 ± 21.6	nr	(44.8–46.6)

Abbreviations: paO₂, oxygen arterial partial pressure; paCO₂, dioxide arterial partial pressure; D(A-a)O₂, alveolar-arterial oxygen gradient; nr, not reported nr, not reported; RBBB, right bundle branch block.

Figure 1 Diagnostic algorithm for elderly patients with suspected PE derived from literature evidence.

Table 3 Implications for clinical geriatric practice

Incidence, prevalence, morbidity and mortality increase steadily with age

PE is the acute cause of death in the elderly that is least suspected by physicians

Comorbidity could influence symptoms and signs

Spectrum of differential diagnosis of PE is wider in elderly patients due to high prevalence of cardio-respiratory diseases in these patients

Higher percentage of elderly patients have high PTP compared with younger patients

Low percentage of elderly patients with suspected PE have nonhigh PTP and negative D-dimer

Specificity of D-Dimer reduces with age

Increased cut-off of D-Dimer could reduce false positives but, unfortunately, could increase false negatives

12-leads electrocardiogram, chest X-ray and echocardiogram could have a lower specificity with respect to younger patients

Hypoxemia and increased alveolar-arterial oxygen gradient have a high sensitivity and low specificity

Respiratory and metabolic acidosis could be more frequent compared with younger patients

Lung scan could be less useful in the elderly for higher percentage of patients with pre-existing pulmonary diseases or abnormal chest X-ray

Single detector and multidetector pulmonary angio-CT seem to be not influenced by age

Pulmonary angiography could be limited in the elderly because of the higher risk of side effects compared with younger patients

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