Patients with PE are characterized as having massive or submassive PE. Massive PE presents in dramatic form, including hypotension and hypoxemia, which may be refractory to therapy. In general, 40 to 50 percent of the pulmonary arterial circuit must be occluded to produce these effects. Patients with preexisting cardiac or pulmonary disease may show the signs of massive PE with lesser degrees of occlusion. Massive PE accounts for approximately 5 percent of all PE but has a mortality of about 40 percent.
Submassive PE presents with normal systemic hemodynamics and hypoxemia, which is correctable with supplemental oxygen. Mortality is low (about 2 percent) if the diagnosis is made and therapy initiated. Failure to make the diagnosis and treat accordingly increases the mortality 10-fold.
A subset of patients with submassive PE warrants special mention. These patients, while having normal systemic pressures on presentation, have evidence of moderate to severe right ventricular dysfunction by physical exam or echocardiography. If not treated, this dysfunction may progress to right ventricular infarction, leading to hypotension and death. Lungs scans reveal perfusion defects of more than 30 percent of the pulmonary circuit. More aggressive therapy than simple anticoagulation may be warranted in this set of patients.89
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