Transcript Pulmonary embolism

Pulmonary embolism
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PE is a consequence of DVT, usually proximal
About 70% of PE, DVT can be found in lower
limb
<chest 2002;122:1440>
KHMC 2011-2013 data DVT/PE =49%
Prevalence of PE among hospitalized
patients-0.4%
Acute case mortality for PE: 7-11%
Overall 3- month mortality rate: 15%
Mortality rate in patients with shcok: 50%
<Thomb Heamost 2002;88:407>
1. Deep veins
accompanied by an artery
surrounded by muscle.
main conduits
2. Superficial veins
located near the skin
superficial to the muscle
regulate body temperature
3. Perforator veins
connect the deep veins
with the superficial veins.
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Lower extremity swelling and pain
 particularly if the swelling is unilateral.
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Nonspecific and Asymptomatic
 Therefore, the accuracy of the clinical diagnosis of DVT is
extremely poor and estimated at 50%.
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Compression ultrasound (US)
 considered the imaging modality of choice
 US examination is extremely accurate for the diagnosis of lower
extremity DVT in the thigh with reported sensitivities ranging
from 88% to 100%, and specificities ranging from 92% to 100%.
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DVT in Occult Malignancy
 DVT and no known risk factors
<Pellerito et al. Introduction to vascular ultrasonography 6th>
Acquired risk factors
Inherited risk factors
Immobilization/trauma/surgery Factor V Leiden
Cancer
Prothrombin G20210 mutation
Prior venous thromboembolism
Protein C deficiency
Medical comorbidities, including
Protein S deficiency
obesity
Antithrombin III deficiency
Increasing age
Pregnancy/postpartum
Stasis of blood flow
Oral contraceptives/hormonal
replacement therapy
Indwelling central venous catheter
Antiphospholipid antibody syndrome
Thrombosis
Hyperhomocysteinemia due to folic
acid deficiency
Intimal Injury
Hypercoagulability
Long-haul air travel
•Symptomatic thrombus
• 99% of symptomatic cases
• Two-point evaluation requires examination
of only the common femoral and popliteal
venous areas
• Asymptomatic thrombus
• 88% of calf thrombus occurs in the
asymptomatic patient
• Calf thrombus is unlikely to lead to clinically
significant pulmonary embolus (PE)
A wide spectrum of illness (feels well ~ shock)
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Symptoms
 Otherwise unexplained dyspnea
KHMC(2011
 Chest pain, either pleuritic or “atypical” -2013)
 Cough
dyspnea
Signs
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Tachypnea (respiratory rate > 20/min)
Tachycardia (heart rate >100/min)
Low-grade fever
Left parasternal lift
TR murmur
Accentuated P2
Hemoptysis
Leg edema, erythema, tenderness
Chest pain
Number
(N=99)
56(57%)
13(13%)
Leg swelling 12(12%)
Atypical
General
weakness
10(10%)
syncope
8(8%)
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F/80
C/C dyspnea
o/s) 1 week ago
PMHx: cerebral infarction, Hypertension
 Clopidogrel, amlodipine, statin, valsartan
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Lab: TnI: 0.02
EKG: poor R progression
Echo: Normal systolic function
CAG: Normal
The most common cause of COPD exacerbation
 lower respiratory tract infection (82%; n = 84)
 followed by PE (5%; n = 5).
 DVT in 6%, with proximal DVT in 4%.
<Respiration 204 2013;85:203–209>
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F/60
C/C syncope
Fall down으로 수상 타병원에서 tibia OR/IF
후 상기 증상 발생하여 전원
PMHx: none
Lab: TnI:0.20 ng/ml, proBNP 13431 pg/ml
EKG: sinus tachycardia HR 108bpm
Chest PA: cardiomegaly
RV
LV
Echocardiography 2 days later
F/U 6 days later
Echo Signs in Acute PE
• RV dilation
• RV hypokinesis
(with sparing of the apex)
“McConnell’s Sign”
• Abnormal interventricular septal motion
(D-shaped LV)
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Tricuspid regurgitation
Pulmonary arterial hypertension
Lack of decreased inspiratory collapse of IVC
Direct visualization of thrombus (rare)
Echo Signs in Acute PE
RV hypokinesis (with sparing of the apex)
“McConnell’s Sign”
Echo
TR peak velocity = 3.5 m/sec
Estimated PASP = 60 mmHg
RV dysfunction in PE
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sustained hypotension (systolic blood pressure <90 mm Hg)
for >15 min secondary to acute PE or a requirement of
inotropes or signs of shock. < 2011 American Heart Association (AHA)
classification , circulation>
RIETE registry N=15530
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Hemodynamically stable
RV dysfunction
 defined as RV dilation on echocardiography or CT
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Elevation of brain natiuretic peptide (BNP)/Nterminal pro BNP (NTproBNP)
or evidence of new RV strain on ECG;
or myocardial necrosis, defined as elevation of
troponin I or T.
Treatment
 Thrombolysis or anticoagulation ???
< 2011 American Heart Association (AHA) classification , circulation>
N Engl J Med 2002;347:1143–50. Thorax 2011;66:75–81.
Number of
patients
256 submassive PE
591 normotensive p
Mortality
30 day mortality
3.4 % in the heparin-plus-alteplase
group
2.2 % in the heparin-plus-placebo
group
90 day mortality
10% in patients with right
ventricular dysfunction by TTE and
concomitant deep vein thrombosis
by CCUS
Thorax 2014;69:109–115.
Circulation 2008;117:1711–16.
Number of
patients
N=848 All patients
N=15520 All patients
Mortality
Right to left ventricular
ratio ≤0.9 on MDCT N=315
13 (4.1%) all cause of death
Right to left ventricular
ratio >0.9 on MDCT N=533
25 (4.7%)
the large RIETE registry also
suggests a 90-day mortality of
around 3% in patients with
submassive PE
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A recent randomised study of thrombolysis in
‘moderate’ PE
 Thrombolysis versus anticoagulation resulted in a
significantly lower sPAP at 48 h.
 Showing this fall in sPAP at such an early time point is
critical to its credibility as a surrogate for PE-related
mortality
 The rate of clot resolution over the first 24 h
< Circluation 2011;123:1788–830>
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Earlier resolution of DVT with thrombolysis
 may also improve outcomes, since further
embolisation may be fatal.
< Am J Med Sci 2011;341:33–9>
37: thrombolysis
35: placebo
[Am J Med Sci 2011;341(1):33–39.]
 416 consecutive patients with
intermediate- or high-risk PE who
survived the acute phase.
 Perfusion lung scans were
performed within 6–8 days after the
onset of treatment
 Prognostic value at 6 months of
residual pulmonary vascular
obstruction (RPVO)
European Heart Journal (2013) 34, 693–701
Heparin+thrombolysis
N=18
Heparin
N=144
26
45
22
20
CHEST 2009; 136:1202–1210
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RV dilatation is a dynamic process.
 A large study indicated that 93% of patients with
submassive PE, treated without thrombolysis, had
normal RV systolic pressure (assessed by
echocardiography) 6 months after diagnosis.
CHEST 2009; 136:1202–1210
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Careful studies have shown that while
thrombolysis improves RV dilatation more than
heparin alone in the first 12 h, the benefits are
lost by 48 h
N Engl J Med 2002;347:1142–50.
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Serious bleeding, in particular intracranial
haemorrhage
The large ICOPER registry
 3% of patients receiving thrombolysis for PE
developed ICH
<Lancet. 1999 Apr 24;353(9162):1386-9>
(Am Heart J 997;134:69-72.)
Am Heart J 1997;134:69-72
Am J Cardiol 2007;99:103–107
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Age>65y
Age >75y
Previous bleeding
Cancer
Metastatic cancer
Renal failure
Liver failure
Thrombocytopenia
Previous stroke
Diabetes
Anemia
• Antiplatelet therapy
• Poor anticoagulant control
• Cormorbidity & functional
capacity↓
• Recent surgery
• Frequent falls
• Alcohol abuse
Low risk 0
Moderate risk 1
High risk≥2
ACCP Guidelines, Chest 2012;141:e4195
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Chronic thromboembolic pulmonary hypertension
Prevalence
 2%–4% of cases in all comers with PE
 It is likely to be much more common in those patients who
have had submassive PE
 Those with acute pulmonary hypertension are at the
greatest risk of CTEPH
<N Engl J Med 2011;364:351–60>
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Main treatment:
 surgical endarterectomy
 very major surgical operation with its own mortality (<5%)
and morbidity
<Circulation 2011;124:1973–81>
N Engl J Med
2011;364:351–60
N Engl J Med 2011;364:351–60
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Very small proportion of patients with
submassive PE will progress to CTEPH
Cannot accurately predict who they will be.
Can monitor patients with submassive PE
Effective, proven therapeutic options for
preventing recurrent PE and treating CTEPH
Circulation Journal Vol.75, 2011
Circulation Journal Vol.75, February 2011
Jiménez D, et al. Thorax 2014;69:109–115
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Major bleeding
 >50% of patients receiving thrombolysis within 1
week of surgery
 20% of patients thrombolysed 1–2 weeks
postoperatively.
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ACCP guidelines
 suggest that recent surgery (excluding recent brain or
spinal surgery or trauma) is a relative contraindication
 the bleeding risk reduces significantly 2 weeks after
surgery
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Previous ischaemic stroke within 3 or 6
months is a contraindication to thrombolysis
in ACCP and ESC guidelines.
A study involving 145 patients with a stroke
within 3 months who received thrombolysis
for a further stroke did not show an increase
in ICH rate.
<Int J Stroke 2012;7:615–22>
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Limited use
 anticoagulation is
contraindicated.
 Routine placement of IVC
filters in submassive PE and
proximal DVT is not
supported by current
evidence.
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If possible, retrievable
filters are recommended
 Simplified dosing regimen
 No dietary restrictions
 Reduced potential for drug interaction
 Predictable anticoagulation and no need for routine
coagulation monitoring
 Can be given at fixed dose
Less labour
intensive
Reduced
administrative
costs
Less impact on
patietns daily life
Improved
quality of life
Improved
compliance
Improved
efficacy and
safety
ACCP 2012 Guidelines
Surgery-associated AVT/PE: recommend 3
months.(1B)
 Nonsurgical transient risk factor: recommend 3
months.(1B)
 Unprovoked DVT/PE and low/intermediate risk
bleeding: suggest extended anticoagulation(2B).
High risk: 3 months (1B)
 Cancer patient with DVT/PE: recommend
extended therapy. LMWH rather than VKA(2C)
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ACCP Guidelines, Chest 2012;141:e4195
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Surgical thrombectomy
Percutaneous catheter-based interventional
techniques
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thrombus fragmentation
rheolytic thrombectomy,
suction thrombectomy
rotational thrombectomy.
Complications
 distal thrombus embolization, perforation or
dissection of cardiovascular structures, pericardial
tamponade, and pulmonary haemorrhage.
massive pulmonary embolism with persistent systolic hypotension but both have
contraindications for thrombolysis
Acute Cardiac Care, September 2012; 14(3): 91–93
Technical success rate: 92.2%
with a significant improvement in
obstruction, perfusion and Miller
indexes (all P < 0.0001).
Four patients : major bleedings
Eight (15.7%) : died in-hospital.
<Catheterization and Cardiovascular Interventions 73:506–513 (2009)>
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Clinical outome
At 90 days, there were no episodes of hemodynamic
decompensation or recurrent VTE among the 59 patients.
Deaths: 1 death from pancreatic cancer in the heparin group
90-day visit .
No major bleeding complications and 4 minor bleeding
episodes: 3 patients (10%) in the USAT group and 1 patient
(3%) in the heparin
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The purpose of the present study was to evaluate the role of this
“safe dose” thrombolysis in the reduction of pulmonary artery
pressure in moderate PE
Am J Cardiol 2013;111:273e277
CHEST 2010 ; 137(2):254–262
Clinical suspicion is important in the diagnosis of DVT & PE
Submassive PE: Normotensive patients with RV
dysfunction
 Pro-BNP and Troponin is clinical predictor of PE prognosis
 RV dysfunction: CT and echocardiography
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 RVD/LVD >1.0 or 0.9
PEITHO trial: fibrolysis prevents clinical deterioration in
patients with evidence of RV dysfunction and myocardial
injury
 The bebefits of thrombolysis come at the cost of major
bleeding
 Bleeding risk factors must be considered especially in old
age patients.
 Low dose fibrolysis can be substituted in submassive PE
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RV
LV
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acute clot are the following:
1. Faintly echogenic (hypoechoic) thrombus
2. Poorly attached thrombus
3. Spongy-texture thrombus
4. Dilated vein (when totally obstructed)
Characteristics usually associated with chronic clot are
the following:
1. Brightly echogenic (hyperechoic) thrombus
2. Well-attached thrombus
3. Rigid texture of thrombus
4. Contracted vein (if totally obstructed)
5. Large collaterals
6. Thickened vein walls
In nearly 50% of initial lower extremity DVT, the vein lumen
remains abnormal with residual vein thrombosis (RVT). Initially
the RVT was deemed a potential masquerader for acute
DVT.64 Over time, chronic thrombus adheres to the vein wall and
causes a diffuse thickening.65 The ability of the vein to collapse
normally, as well as the restoration of a normal-sized lumen, are
very helpful in excluding the presence of chronic thrombus. If the
findings remain perplexing, a repeat study in 24 to 72 hours will
confirm stability or demonstrate progression.
 RVT may be a marker of increased risk for recurrent DVT. Patients
without RVT can be treated with only 3 months of anticoagulation.
RVT may be a marker of a prothrombotic state, and individuals
with RVT might be prone to recurrent episodes of DVT
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The daily use of sized-to-fit, 30– to 40–mm Hg knee-high graduated elastic compression
stockings (ECS) for 2 years after the diagnosis of first-episode proximal DVT was found in 3
European single-center RCTs to be associated with marked reductions in the frequency of
PTS.244–246 Limitations of these studies included lack of placebo control, blinding, and separate
delineation of outcomes in IFDVT patients. An RCT that assessed the use of ECS starting 1 year
after diagnosis in DVT patients without signs of PTS did not find evidence of benefit in preventing
the subsequent development of PTS.247 No studies directly address the comparative efficacy of
thigh-high versus knee-high ECS in IFDVT patients. Limitations of ECS therapy include patient
noncompliance due to difficulty in applying the garments, discomfort while wearing them daily,
and their cost. Also, no RCT has specifically addressed the use of thigh-high ECS in IFDVT
patients. Nevertheless, given the concordance of the results of the RCTs evaluating early use of
ECS and the very low likelihood of causing harm with this intervention, we recommend daily use
of 30– to 40–mm Hg knee-high ECS for patients with IFDVT for at least 2 years after the diagnosis
of proximal DVT.
Recommendations for Use of Compression Therapy 1. Patients with IFDVT should wear 30– to
40–mm Hg knee-high graduated ECS on a daily basis for at least 2 years (Class I; Level of
Evidence B). 2. In patients with prior IFDVT and symptomatic PTS, daily use of 30– to 40–mm
Hg knee-high graduated ECS is reasonable (Class IIa; Level of Evidence C). 3. In patients with
prior IFDVT and severe edema, intermittent sequential pneumatic compression followed by
daily use of 30– to 40–mm Hg knee-high graduated ECS may be considered (Class IIb; Level of
Evidence B).
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Thrombolysis should be considered when a
patient initially treated with anticoagulation
alone develops worsening cardiovascular
instability or respiratory failure.
Failure to improve following thrombolysis
should trigger reassessment for residual clot
or complication of PE.
Surgical embolectomy is preferable to rethrombolysis for persistent obstructing acute
PE.