Silent Pulmonary Embolism in Patients with Deep Venous Thrombosis: A Systematic Review



      To determine, by systematic review of the literature, the prevalence of silent pulmonary embolism in patients with deep venous thrombosis.


      Twenty-eight included published investigations were identified through PubMed. Studies were selected if methods of diagnosis of pulmonary embolism were described; if pulmonary embolism was stated to be asymptomatic; and if raw data were presented. Studies were stratified according to whether silent pulmonary embolism was diagnosed by a high-probability ventilation-perfusion lung scan using criteria from the Prospective Investigation of Pulmonary Embolism Diagnosis, computed tomography pulmonary angiography, or conventional pulmonary angiography (Tier 1), or by lung scans based on non-Prospective Investigation of Pulmonary Embolism Diagnosis criteria (Tier 2).


      Silent pulmonary embolism was diagnosed in 1665 of 5233 patients (32%) with deep venous thrombosis. This is a conservative estimate because many of the investigations used stringent criteria for the diagnosis of pulmonary embolism. The incidence of silent pulmonary embolism was higher with proximal deep venous thrombosis than with distal deep venous thrombosis. Silent pulmonary embolism seemed to increase the risk of recurrent pulmonary embolism: 25 of 488 (5.1%) with silent pulmonary embolism versus 7 of 1093 (0.6%) without silent pulmonary embolism.


      Silent pulmonary embolism sometimes involved central pulmonary arteries. Because approximately one third of patients with deep venous thrombosis have silent pulmonary embolism, routine screening for pulmonary embolism may be advantageous.


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      Linked Article

      • Looking for Asymptomatic Pulmonary Embolism in Patients with Deep Vein Thrombosis: Is It the Right Practice?
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          The systematic review by Stein et al1 proposing using ventilation-perfusion (V/Q) scanning looking for asymptomatic or silent pulmonary thromboembolic disease in patients presenting initially with lower limb deep venous thrombosis raises concern. Although not doubting the concurrent nature of disease, the first question to be asked is whether the significance, nature, severity, or outcome from identifying concurrent pulmonary thromboembolism among patients managed as ambulatory deep venous thrombosis schemes is actually different from that presenting overtly with pulmonary thromboembolism?
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      • Routine Screening for Silent Pulmonary Embolism Is Harmful and Unnecessary
        The American Journal of MedicineVol. 123Issue 12
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          In their recent article, Stein et al1 discuss the prevalence of silent pulmonary embolism and conclude by suggesting a role for “routine screening” for pulmonary embolism in all patients with deep vein thrombosis. While I appreciate the contribution their review makes to our knowledge of this field, their discussion in favor of routine screening for silent pulmonary embolism is cursory and falls far short of adequately addressing the myriad dangers of their proposal. At the most fundamental level, diagnostic testing should be done in order to change or inform clinical management.
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