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Paradoxical embolism. An underrecognized problem
1Section on Pulmonary and Critical Care Medicine, Bowman Gray School of Medicine, Winston-Salem, NC, USA.
Abstract:
Despite reports of the clinical presentations and devastating consequences of paradoxical embolus (PDE) for more than a century, this diagnosis continues to be frequently missed. Because the prevalence of patent foramen ovale (PFO) is 27 to 35% in the normal population and the presence of deep vein thrombosis or pulmonary embolus may not be clinically obvious, a high suspicion for PDE is needed in the event of unexplained arterial occlusion. While contrast echocardiography and transcranial Doppler ultrasound have facilitated clinical recognition of PDE, the optimum approach to diagnosis requires clarification. Primary therapy for patients with PDE is anticoagulation, with thrombolytics considered in carefully selected individuals, but there is little published information regarding long-term treatment and outcomes. Prevention remains essential whenever possible. It is not yet defined whether prophylactic treatment of persons with recognized predispositions to PDE (eg, PFO and pulmonary hypertension) is beneficial.
Insights
Paradoxical embolus (PDE) is often missed despite its serious arterial occlusion consequences. High suspicion for PDE is crucial in unexplained arterial events, especially with patent foramen ovale (PFO).
Area of Science:
- Cardiology
- Neurology
- Vascular Medicine
Background:
- Paradoxical embolus (PDE) remains a frequently missed diagnosis despite over a century of reports on its clinical presentation and severe outcomes.
- Patent foramen ovale (PFO) affects 27-35% of the general population, increasing the risk of PDE.
- Deep vein thrombosis or pulmonary emboli may not be clinically apparent, complicating PDE diagnosis.
Observation:
- A high index of suspicion for PDE is necessary when encountering unexplained arterial occlusion.
- Contrast echocardiography and transcranial Doppler ultrasound aid in recognizing PDE.
- Optimal diagnostic strategies for PDE require further definition.
Findings:
- Anticoagulation is the primary treatment for PDE.
- Thrombolytics are reserved for carefully selected PDE patients.
- Limited data exists on the long-term management and outcomes of PDE.
Implications:
- Prevention of PDE is paramount.
- The benefit of prophylactic treatment for individuals with predispositions like PFO and pulmonary hypertension is yet to be determined.
- Further research is needed to clarify diagnostic and therapeutic guidelines for paradoxical embolus.