Transcript 1410_Bartholomew_AD5E3x

Pulmonary Embolism A Team Approach to Diagnosis and Management
John R. Bartholomew, MD, FACC, MSVM
Professor of Medicine – Cleveland Clinic Lerner College of Medicine
Section Head – Vascular Medicine
Departments of Cardiovascular Medicine and Hematology/Oncology
Disclosures
None are related to my presentation today
• Research Support:
• Siemens
• Consultant:
• Boehringer-Ingelheim
• Daiichi Sankyo
• Portola Pharmaceuticals
Pulmonary Embolism
• Common, lethal disease, frequently overlooked
• Mortality - approximately 2% to 6% of patients with
hemodynamically stable PE
• Mortality - 30% or more of patients presenting with
hemodynamic instability or shock
• Most common preventable cause of death among hospitalized
patients
• Death can be reduced by prompt recognition, diagnosis and
treatment
Am J Respir Crit Care Med 2010;181:501-506
Circulation 2013;127(1):e6 e245
JAMA 2013;309(2):171-180
AHA - 2015 Statistics
PE is the 3rd Leading Cause of CV Death
PE
MI
Stroke
Circulation 2015;131:e29-e322
© 2015 by the American College of Cardiology Foundation and the American
Heart Association, Inc. . Published by American Heart Association.
Natural History of Pulmonary Embolism
Prog Cardiovasc Dis 1975;XVII (4) 259-270
Treatment Options for Pulmonary Embolism
• LMWH, Fondaparinux, IV or SC heparin
• Rivaroxaban, Apixaban - monotherapy
• Dabigatran or Edoxaban –transition therapy - (after 5
days of a parenteral anticoagulant)
• Thrombolytic therapy
• Warfarin
• Additional options
Intensive Review of Internal Medicine
CHEST 2016; 149(2):315-352
Risk Stratification for Acute PE
•
•
•
•
•
Normal (BP + RV) =
Low Risk:
Anticoagulation
(Hospital mortality <4%)
Clinical examination
(BP, HR, O2 saturation)
Biomarkers (Troponin, BNP)
RV and PA pressures-ECHO
RV and PE size (Chest CT)
Normal BP
 Biomarkers,
RV dysfunction:
Controversial
(Hospital mortality 5-10%)
Shock =
High Risk:
Lysis or Embolectomy
± IVC filter
(Hospital mortality 30%)
Chest 2008; 133 (suppl) 454S-545S
PE Prognosis – Disposition Assistance
Pulmonary Embolism Severity Index (PESI)
Original PESI
(Class I and II = low risk)
Points
Age
Male sex
History of cancer
Heart failure
Chronic lung disease
Pulse ≥110 bpm
BP <100 mmHg
Respiratory rate ≥30 bpm
Temperature <36 degrees
Altered mental status
O2 saturation < 90%
Age in yrs.
Risk categories
Class I (<65 points)
+10
+30
+10
+10
+20
+30
+20
+20
+60
+20
Simplified PESI
(Score of ≥1 = high risk)
Points
Age > 80 y
History of cancer
COPD
HR ≥110 bpm
Systolic BP <100 mmHg
Arterial O2 sat < 90%
+1
+1
+1
+1
+1
+1
Simplified PESI:
Low risk, 30-day mortality of 1%
High risk 30-day mortality of 10.9%
30 day all-cause mortality, %
0-1.6%
Class II (66-85 points)
1.7-3.5%
Class III (86 – 105 points)
3.2-7.1%
Class IV (106-125 points)
4-10.4%
Am J Respir Crit Care Med 2005;172:1041
Class V (>125 points)
10-24.4%
Arch Intern Med. 2010;170:1383
Most Patients with PE do well, but some do not!
Predictors of Mortality from PE and their Influence on Clinical Management
Chest 2002;122:1801-1817
Thromb Haemost 2008;100(5):747-751
Imaging Insights 2011;2:705-715
Case Report
• 69 year old female
• PMH - HTN, diabetes mellitus, asthma
• Previous PE after surgery in 2010
• Left total knee replacement
• LMWH for DVT prophylaxis
Case Report
• Developed shortness of breath, chest pain and syncope
• 911 called, BP < 90 mmHg (responded to IV fluids)
• Required O2
• ER – CPTA positive an acute saddle PE
• Started on full dose heparin
• Thrombocytopenia noted (heparin stopped)
• Argatroban initiated
Classification of Acute PE
Massive PE (~5%)
Submassive PE (~25%)
Low Risk PE (~70%)
Hypotension > 90 mmHg,
syncope or cardiac arrest
Normotensive
Normotensive
Respiratory failure
Right ventricular
dysfunction, elevated
biomarkers
Normal right ventricle and
normal biomarkers
Often fatal if aggressive
treatment not initiated
Increased risk of adverse
outcomes
Good prognosis with
anticoagulation alone
Lancet 1999;353:138
Circulation 2011; 123: 1788-1830
Circulation 2013; 127: 2458-2464
Outcomes in Pulmonary Embolism
Chest 2002;121:877-905
Case Report
• Transferred – Cleveland Clinic Medical ICU
- BP 105/63, HR 108, RR 22)
- Pulse oximetry - 94% on 4 liters of oxygen
• Mild distress
• Echo: moderate RV dilation and moderate to
severe RV dysfunction
• Duplex US: left leg femoral-popliteal DVT
Case Report
• Hemoglobin 12, platelets 18,000
• BUN 18, creatinine 1.21
• INR 1.1
• aPTT 57 seconds (target 46-84)
• PF4 strongly positive
Case Report - PERT Call
• Develops atrial fibrillation with RVR 148
- oxygen requirements increasing
- more short of breath
- hypotensive again
• Troponin positive
• Platelet count 24,000, hemoglobin stable
• PERT TEAM CALLED
Treatment Options for Submassive or Massive PE
• Thrombolysis (full dose or ½ dose)
• Catheter directed thrombolytic therapy ± ultrasound guided
• Catheter interventions and devices without thrombolysis
- thrombus fragmentation
- thrombectomy
- suction embolectomy
• Acute pulmonary embolectomy
• Placement of inferior vena cava filters
What to do Next?
What do the Guidelines tell us?
Grade 2C: weak recommendation, low or very low quality evidence
CHEST 2012; 141:e419s-494s
Class IIa; Level of Evidence B = Benefit >> than risk. Reasonable to perform treatment being useful/effective.
Class IIb; Level of Evidence C = Benefit > risk. Limited population studied. Procedure/treatment may be
considered. Recommendations/usefulness, efficacy less well established.
Circulation 2011;123:1788-1830
Recommendations
Class Level
Thrombolytic therapy is recommended
I
B
Surgical pulmonary embolectomy is recommended for
patients in whom thrombolysis is contraindicated or has
failed
I
C
IIa
C
Percutaneous catheter-directed treatment should be
considered as an alternative to surgical pulmonary
embolectomy for patients in whom full-dose systemic
thrombolysis is contraindicated or has failed
Class I: evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective
Class IIb: usefulness/efficacy is less well established by evidence/opinion
Level B: data derived from a single randomized clinical trial or larger non-randomized studies
Level C: consensus of opinion of the experts and/or small studies, retrospective studies, registries
European Heart J 2014;35:3033-3080
Circulation 2004;110(6):744-749
Chest 2006;129(4):1043-1050
Factors Associated with Clinical Deterioration
Shortly after PE (in our patient)
• Hypotension
• Hypoxia
• Coronary artery disease
• Residual deep vein thrombosis
• Right heart strain on echocardiogram
• Elevated biomarkers
• RV enlargement on CT
Circulation 2004;109(20):2401-2404
Thorax 2104;68:835-842
What did we Do?
Case Report - PERT CALL
• 50 mg tissue plasminogen activator infused
over 2 hours
• At the end of the infusion
- heart rate low 70’s (NSR)
- blood pressure normalized
- oxygen requirements decreased
- clinically significantly improved
- discharged home 10 days later on warfarin
Pulmonary Embolism:
Which Therapy to use ?
• Best treatment unknown – no standard approach
• Strategies depend on the individual hospital service
- Medical
- Surgical
- Other
• No consistency in decision making
• No accepted algorithm
• No single team approach
PE Therapeutic Options: All Over the Map
Anticoagulation
IV Thrombolysis
Catheter Directed
Thrombolysis
IVC Filter
Pharmaco-Mechanical
Catheter Treatment
Surgical
Embolectomy
ECMO
Slide courtesy of PERT Consortium
Which Therapy to Use?
• Best treatment unknown
- No standard approach
- No “appropriate use criteria” for intervention
• Strategies all over the map
- Practice varies by medical service, location, size
- No standard algorithm or consistency in decision-making
- No single team
- No centralized locations for care or “centers of excellence”
- No systematic evaluation of results
How do we decide whether to “intervene” and by what
modality? Who decides? What is the endpoint?
Treatment Gap in Pulmonary Embolism
• <5% of patients with PE receive “advanced therapy”, including
those with clear indications (hypotension, RV dysfunction,
biomarkers, etc.)
• Many more are eligible than receive
• Reasons:
- failure to recognize potential benefit and integrate data in “real time”
- fear of complications
- inability to respond rapidly (systems issues)
- paralysis in decision-making
Slide courtesy of PERT Consortium
Multidisciplinary PE Response Teams:
Making Order out of Chaos
Complex risk stratification and decision making
The Perks of PERTs
• PERTs provide rapid bedside evaluation and risk stratification
of patients with acute PE
• PERTs help interpret recommendations from 3 sets of
guidelines in the context of the individual patient.
• PERTs facilitate access to advanced therapies such as systemic
fibrinolysis, catheter-directed therapy, surgical pulmonary
embolectomy, and IVC filter insertion.
• PERTs guide the utilization of advanced techniques such as
ECMO for critically-ill PE patients.
Slide courtesy of PERT Consortium
PERT Program Flow Map
Expeditious input and clinical judgment from multiple specialties to optimize therapy
Handoff to
therapeutic site
ED
Hospital
OSH
PERT fellow:
History
Physical
Labs
EKG
Echo
CT-PE
Ultrasound leg
Low Risk
A/C
ACTIVATE PERT
Submassive
Lytic
CDT
Massive
Vortex
Electronic Meeting
Vascular Medicine
Cardiac Surgery
ICU/Pulmonary
Cardiology
Interventional Radiology
Hematology
ECMO
Surgery
Slide courtesy of PERT Consortium
Summary
• The best methods for risk stratification (ACCP, AHA, ESC)
remains to be determined.
• The optimal strategy for selection of advanced therapies for
moderate and high-risk PE patients is unclear.
• The role of advanced circulatory support for PE has yet to be
defined.
• Multidisciplinary PE Response Teams provide real-time
individualized bedside evaluation and recommendations
until definitive management algorithms are established.
Slide courtesy of PERT Consortium