Pulmonary Embolism - PDF

Pulmonary embolism Assist. Prof. Octavian Amariței, MD, PhD student Assoc. Prof. Cristian Guțu, MD, PhD “Dunarea de Jos” University of Galati  What is PE? Pulmonary arterial bed occlusion, most frequently due to a thrombus 3rd most frequent cau...

Pulmonary embolism Assist. Prof. Octavian Amariței, MD, PhD student Assoc. Prof. Cristian Guțu, MD, PhD “Dunarea de Jos” University of Galati  What is PE? Pulmonary arterial bed occlusion, most frequently due to a thrombus 3rd most frequent cause of cardiovascular death, after ACS and STROKE one of the most frequently preventable causes of death among hospitalized patients.  …it all starts when blood stops… Venous return decreases Blood stagnates Thrombus forms  Venous Thrombembolism Pulmonary Deep Venous Thrombosis Thrombembolism (DVT) (PE)  Epidemiology The incidence in general population is around 60-120 cases per 100,000 people per year The incidence raises exponentially in older people: ->70-79 yo: 300-500 cases/100000 ->25-35 yo: 30 cases/100000 More frequent in hospitalized patients  Predisposing factors Classified according to: →the degree of risk increase: major, moderate, minor →the history: genetically inherited, or acquired →the duration for which the factor is present: transient or persistent Major predisposing factors for DVT Major surgical intervention (transient) Hip or knee replacement (transient) Lower limb fractures (transient) Spinal cord injuries (transient) Major trauma (transient) Moderate predisposing factors for DVT Pregnancy / hormonal treatment / birth control pills Chronic heart failure (acquired)(persistent) Thrombophilia (inherited)(persistent) Central venous catheters Chemotherapy Malignancy  Minor predisposing factors for DVT Age Obesity Varicose veins Laparoscopic surgery Prolonged immobilization in a seated position  Up to 30% of cases with PE are idiopathic  Hemodynamic consequences Thrombus obstruction Acute pulmonary hypertension Increased RV afterload RV failure Hemodynamic collapse Death  How big is the Thrombus? a.k.a What percentage of the lung has been infarcted? Small thrombus → travels more and blocks smaller caliber arteries (segmental/subsegmental arteries) → DISTAL PE BIG THROMBUS → blocks lobar branches or even the main pulmonary arteries → PROXIMAL PE The more PROXIMAL the thrombus is located, the higher the MORTALITY → Proximal PE presents with a more dramatic clinical picture →Distal PE can have a milder course, and the clinical presentation can be less pronounced  Symptoms Dyspnea (80%) Pleuritic chest pain (52%) Retrosternal chest pain (12%) Cough (20%) Syncope (19%) Hemoptysis (11%) VERY UNSPECIFIC VERY DECEPTIVE  Signs Tachypnea (70%) Tachycardia (26%) DVT associated signs (15%) Cyanosis (11%) Fever (7%) VERY UNSPECIFIC VERY DECEPTIVE Diagnosis IMAGING WELLS PROBABILITY SCORE VTE or not VTE?  ECG Tachycardia – the most frequent change RV strain pattern (TWI in inferior leads and V1-V4) „S1Q3T3” pattern (neg S wave in I, Q wave and TWI in III) – high specificity but low sensitivity Can highlight other pathologies (ACS)  Chest X-ray Used mainly for excluding other causes Low sensitivity and specificity Can show athelectasis, pleural effusion, cardiomegaly, etc. Can present specific sign like Westermark or Hampton hump, but they also have low sensitivity ABG (arterial blood gas) Changes in O2 and CO2 levels Changes in pH Moderate sensitivity and very low specificity Can evaluate the need for ventilation Cardiac biomarkers BNP, Nt-proBNP, troponins Can increase due to RV strain Low specificity  D-Dimers Fibrin degradation products High sensitivity, low specificity Used only to rule out patients with low probability Can also be elevated in pneumonia, ACS, Stroke, etc. Ultrasound of the lower limbs Fast, non-invasive Evaluates DVT Highlights the non-compressibility of veins Can visualize the thrombus Higher sensitivity for proximal DVT  CTPA (computed-tomography pulmonary angiography) High sensitivity and specificity Quick, relatively available Highlights alternative diagnosis if PE was excluded  V/Q scan Ventilation-perfusion scintigraphy Alternative to CTPA Lower availability, higher cost Lower doses of radiation (CKD) Can be false-positive (other lung pathologies also presents with V/Q mismatch)  Echocardiography Fast, non-invasive Used in EMERGENCY situations (shock) when CT angiography or V/Q scan is unavailable, or takes to much time Detects acute pulmonary hypertension and RV strain/failure Can show specific signs (McConnell sign) PESI – Pulmonary embolism severity score Is every PE the same?  Treatment REPERFUSION ANTICOAGULATION PROPHYLAXIS  -ACUTE PHASE- Supportive therapy (Depending on the case!) →Oxigenotherapy →Saline →(+) inotropes (dobutamine) →Vasopressors  -ACUTE PHASE- REPERFUSION (Massive PE, shock, RV disfunction) →Thrombolysis: Uses thrombolytic agents (tPA) to dissolve the thrombus Can be used in the first 2 weeks NOT TO BE USED IN LOW RISK PATIENTS  -ACUTE PHASE- REPERFUSION (Massive PE, shock, RV disfunction) →Mechanical thrombectomy →Catheter directed thrombolysis when IV thrombolysis is contraindicated  -ACUTE PHASE- ANTICOAGULATION (Every PE case) →DOES NOT DISSOLVE EXISTING CLOTS →prevents further formation of clots →UH or LMWH used initially, then oral medication (+/- overlap)  -CHRONIC PHASE- ANTICOAGULATION (Every PE case) →Provoked PE: -3 months →Unprovoked PE: -at least 6 months (depending on the risk factors) →Recurrent or idiopathic PE: LIFETIME  PROPHYLAXIS →Early postop mobilization →Graduated compression stockings →Intermittent pneumatic compression →IVC filter →Anticoagulation (postop, immobilization periods)  PE can progress PE - „The great very fast, very VTE can present as masquerator” dramatic DVT, PE, or both TAKE HOME MESSAGES Probability and Severity scores Primary prevention helps guide the for DVT in high risk management Treatment is ANTICOAGULATION +/- patients is needed THROMBOLYSIS (if high risk)