Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease.. Söhne M, Ten Wolde[r]
(1)Pulmonary Embolism
Diagnosis and Management Sherstin T Lommatzsch, MD
Assistant Professor of Medicine
(2)Objectives
• Definitions • Diagnosis
(3)Definitions
– Obstruction of a pulmonary artery:
• Air • Fat
• Tumor
(4)Definitions
• Acute vs Chronic
– Acute:
• Symptoms develop within to hours following obstruction
– Chronic:
• Symptoms develop over years due to pulmonary
(5)Definitions
• Massive vs Submassive
• Massive
– Systolic blood pressure < 90mmHg or decrease of > 40mmHg from baseline lasting at least 15 min – Likely if signs of elevated
central venous pressure – Risk for death 24-72 hrs
• Submassive
– All others
(6)Definitions
• Saddle Pulmonary Embolism
– Caught at bifurcation of the right and left
(7)Definitions
(8)Diagnosis
High Clinical Suspicion!!!
Symptoms
• Dyspnea (73%)
• Pleuritic pain (44%) • Calf/Thigh pain (44%)
• Calf/Thigh swelling (41%)
• Cough (34%)
• Orthopnea (28%)
• Wheezing (21%)
Signs
• Tachypnea (54%)
• Tachycardia (23%)
• Rales (18%)
• Diminished breath sounds
(17%)
• Loud P2 (15%)
(9)Diagnosis
High Clinical Suspicion!!!
• Clinical Suspicion Alone:
– Sensitivity = 85%
(10)Diagnosis
(11)Diagnosis
Laboratory Studies
• D-Dimer
– ELISA or Quantitative Rapid
• Sensitivity = 90%
• ABG
– Misleading:
• 18% have normal PaO2
• 6% have normal a-A gradient
• BNP
– Sensitivity 60% – Specificity 62%
– More prognostic value • Troponin I or T
– Elevated in 30-50% – More prognostic Value
Radiographic Studies
• CXR
– Findings also seen in other pathology
• Pulmonary Angiography
– Gold Standard
• Spiral CT
– Sensitivity = 83% – Specificity = 96%
• V/Q Scan
– Excludes PE if Normal
(12)Diagnosis
Wells Criteria Clinical Suspicion PLUS
(13)Date of download: 10/28/2013 Copyright © 2012 American Medical Association All rights reserved
From: Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer Testing, and Computed Tomography
JAMA 2006;295(2):172-179 doi:10.1001/jama.295.2.172
Figure Legend:
(14)Date of download: 11/3/2013 Copyright © 2012 American Medical Association All rights reserved
From: Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical
Probability, D-Dimer Testing, and Computed Tomography
JAMA 2006;295(2):172-179 doi:10.1001/jama.295.2.172
*Excludes 29 patients treated with anticoagulant therapy for reasons other than venous thromboembolism.†Excludes 69 patients treated with anticoagulant therapy for reasons other than venous thromboembolism
Figure Legend:
(15)Treatment
(Standard) GOAL
(16)Treatment
(Standard)
Immediate
• Low Molecular Weight
Heparins (SC)
– enoxaperin, nadroparin, tinzaparin, daltiparin
• Factor Xa Inhibitor (SC)
– fondaparinux
• Unfractionated Heparin (IV or SC)
Long-Term
• Vitamin K Inhibitors
– Warfarin
• Factor Xa Inhibitor
(17)Treatment
(Standard)
Immediate
• Low Molecular Weight
Heparins (SC)
– enoxaperin
• Factor Xa Inhibitor (SC)
– fondaparinux
• Unfractionated Heparin (IV or SC)
First Choice
• Less Major Bleeding Complications
• Fewer Recurrent Thromboembolic Events • Lower Mortality
Second Choice • Persistent Hypotension
• Creatinine Clearance < 30mL/min • Increased Bleeding Risk
• Possible Thrombolysis
(18)Treatment
(Standard)
Immediate
• Low Molecular Weight
Heparins (SC)
– enoxaperin, nadroparin, tinzaparin, daltiparin
• Factor Xa Inhibitor (SC)
– fondaparinux
• Unfractionated Heparin (IV or SC) – weight based protocol
First Choice
• Less Major Bleeding Complications
• Fewer Recurrent Thromboembolic Events • Lower Mortality
• Ensures rapid and adequate therapy • Less Thrombocytopenia
• Dosing Convenience
Second Choice
• Persistent Hypotension
• Creatinine Clearance < 30mL/min • Increased Bleeding Risk
• Possible Thrombolysis
(19)Treatment
(Standard)
Long-Term
• Vitamin K Inhibitors
– Warfarin
• Factor Xa Inhibitor
– Rivaroxaban • Oral Variable Dosing -> INR
• Goal INR 2-3 • Reversible
• Oral Fixed Dosing
• Renal Adjustment Required
(20)Treatment
(Standard)
Long-Term
• Vitamin K Inhibitors
– Warfarin
• Factor Xa Inhibitor
– Rivaroxaban • Oral Variable Dosing -> INR
• Goal INR 2-3 • Reversible
• May begin during 1st24H of full
heparin, etc therapy
•5 Day overlap with heparin/etc AND •24H of INR = 2-3
•Do NOT begin prior to heparin/etc
• Oral Fixed Dosing
• Renal Adjustment Required
(21)Treatment
(Standard) Complications • Significant Bleeding
– Risk Factors
– Bleeding Risk (%)
• Older Age (> 65) • Thrombocytopenia • Fall Risk
• Hepatic Disease
• Compliance Concerns
• Concominent Anti-Platelet Therapy
• Recent Surgery • Cancer
• Renal Disease • Alcohol Use
• Diabetes Mellitus
• Prior Significant Bleeding
First Months Per Year Following
• No Risk Factors 1.6 0.8
• 1 Risk Factor 3.2 1.6
(22)Treatment
(Standard) Duration
• Based on risk of recurrence following 1st PE
– Provoked versus Unprovoked
Trauma
Immobilization Surgery
Drugs
Pregnancy
3 Months 3 Months
? Longer
• Without Anticoagulation •5 yr 25% Risk
Recurrence
• With Anticoagulation • 1st yr: 8.8%
(23)Treatment
(Emerging)
• Systemic Thrombolysis
– Considered in patients with confirmed pulmonary embolism AND hypotension
– No difference in mortality or recurrent
thromboembolic events when compared to anticoagulation alone.
– Some improvement in various outcomes:
• Acute Improvement Right Ventricular Function
• Lower Long-term Pulmonary Artery Pressures
(24)Treatment
(Emerging)
• Systemic Thrombolysis
– Agents
• Recombinant tissue plasminogen activator (tPA)
– Most commonly used
• Streptokinase
• Recombinant human urokinase
– Infusion Method
• bolus
(25)Treatment
(Emerging)
• Systemic Thrombolysis
– Massive PE without hypotension
• Dilated Right Ventrical
• Right Ventricular Dysfunction
• Elevated BNP
• Elevated Troponin
• Severe Hypoxemia
• Persistent Tachycardia
• Right Ventricular EKG Changes
(26)Treatment
(Emerging)
• Systemic Thrombolysis
– Risk
• Bleeding Intracranial Hemorrhage
– Contraindications (similar to thrombolysis in CVA) • Intracranial neoplasm
• Intracranial surgery within months
• GI Bleeding or other significant internal bleeding within prior months • Uncontrolled HTN: SBP>200mmHg and/or DBP>110mmHg
• Trauma within preceding months • Ischemic CVA > months prior to PE • Bleeding coagulopathies
• Surgery within prior 10 Days
(27)Treatment
(Emerging/Alternative)
• Catheter Directed Thrombolysis • Embolectomy
– Surgical versus Catheter
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