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Pulmonary embolism
- 1. Pulmonary Embolism Salah Abusin, MD, MRCP Cardiology Fellow Chicago, IL Secretary General Sudanese American Medical Association
- 2. Outline • Definition • Management • Risk Factors – Anticoagulation • Types – Thrombolysis • Natural History – IVC filters • Symptoms – Embolectomy • Signs • Surgical • • Catheter Based Investigations • Diagnosis
- 4. History • A 61year old male – New onset shortness of breath for 4 days. – He also noticed a cough, with blood tinged sputum. – He had no chest pain, no orthopnea or paroxysmal nocturnal dyspnea, or fever. – He used his albuterol inhaler several times with no improvement in his shortness of breath • .
- 5. • Past history: – Hypertension – Asthma – Remote history (10 years prior to current presentation) of left lower limb swelling that subsided after treatment for 6 months. • Social history: Smoker 40 pack year history • Family history: no relevant family history. • Drug history: – fluticasone/Salmeterol combination inhaler twice daily, – albuterol inhaler as needed for shortness of breath – hydrochlorothiazide 12.5mg once daily
- 6. Physical Examination: • VitalSigns: – HR 113/min, – BP 150/93, – respiratory rate 22/min, – oxygen saturation via pulse oximetry 89% on room air, – temperature 97.2° F (36.2 °C)
- 7. • HEENT: (Head,Eyes, Ear, Nose, Throat examination) was normal. • JVP was not raised. • Chest clear no wheezes, or crackles. • Abdomen soft non tender, no palpable liver, spleen. • Lower extremities: no edema, no other abnormalities • PEFR (peak expiratory flow rate) was above 75% of predicted
- 8. What is yourdifferential diagnosis? What test would you like to perform next?
- 9. Investigations • Chest Xray Clear Lung fields • ECG Sinus Tachycardia • Basic metabolic panel (BMP) includes Na, K, HCO3, Chloride, BUN, Creatinine was within normal limits. • Complete blood count: Hb 15.9, WBC 7200 with normal differential, platelet count 270. • Liver function test, and liver enzymes were within normal limits.
- 10. Arterial Blood Gason Room Air • pH 7.42 (normal) • pCO2 33.2 (mildly reduced) • pO2 55 (moderately reduced) • Oxsat 87%
- 11. What would youlike to do next?
- 12. CT Chest –PE Protocol
- 13. Definition of PulmonaryEmbolism • obstruction of the pulmonary artery or one of its branches by material (eg, thrombus, tumor, air, or fat) that originated elsewhere in the body
- 14.
- 15. Types • Acute – Massive (BP <90/40 >15mins) – Submassive – doesn’t meet above definition • Chronic • Saddle PE – Embolus lodges at the Main PA bifurcation
- 16. Natural History • 30%die if untreated • Usually due to recurrent PE
- 18. Symptoms • Dyspnea at rest or with exertion (73%) • Pleuritic pain (44 %), • calf or thigh pain (44%), • calf or thigh swelling (41%), • cough (34%), • >2-pillow orthopnea (28% ), • wheezing (21 %) PIOPED II. Stein PD , Beemath A et al Am J Med. 2007;120(10):871.
- 19. Signs • tachypnea (54%), • tachycardia (24%), • crackles (18%), • decreased breath sounds (17%), • Loud S2 (15%), • Raised JVP (14 %) PIOPED II. Stein PD , Beemath A et al Am J Med. 2007;120(10):871.
- 20. Laboratory Investigations • ABGs – Hypoxemia – Hypocapnia – Respiratory alkalosis – Hypercapnia, Resp acidosis (if massive) – Metabolic acidosis (if massive) • Troponin – Elevated in moderate to severe PE
- 21. D dimer • Fibrin degradation product • Is elevated in most patients with PE • High negative predictive value • i.e. useful to rule out PE in patients with low to intermediate pretest probability
- 22. ECG • Sinus tachycardia •Non specific ST/T changes • Classical findings are uncommon – S1Q3T3 pattern, – RV strain, – new incomplete RBBB
- 23. Chest Xray • Usuallyabnormal but doesn’t differentiate PE from other diagnoses PE No PE Atelectasis or a pulmonary 69% 58% parenchymal abnormality Pleural Effusion 47% 39% Normal 12% Stein et al Chest. 1991;100(3):598
- 24. VQ Scan • Interpretedas probability i.e. – Low Probability – Intermediate Probability – High Probability • Diagnosis of PE using VQ scan requires integration of the pretest probability • Normal VQ Scan virtually excludes PE
- 26. CT Chest • Advantages – High Specificity for main, lobar and segmetal vessels – Rapidity – Diagnosis of other disease entities • Disadvantages – Availability – Expense – Less sensitivity with subsegmental vessels – Contrast Load
- 27. Diagnosis • Clinical findingsare generally non specific, variable, and common with other conditions • Results of Diagnostic Investigations (VQ, CT) have to be integrated with the pretest probability of PE
- 28.
- 30. Management • Anticoagulation (Acute) – Unfractionated Heparin – Low Molecular Weight Heparin – Fondaparinux • Anticoagulation (Chronic) – Warfarin • New agents – Dabigatran – Rivaroxaban
- 31. Unfractionated Heparin • Provento work since 1960 • Intravenous – Bolus of 80u/kg followed by infusion at 18u/kg/hr – Titrate to target PTT 1.5-2.5x the control aPTT • Subcutaneous – After IV bolus of 5000u, 250u/kg BID – SQ bolus of 333u/kg – aPTT Not monitored
- 32. LMW Heparin • Administeredsubcutaneously • Examples include – Enoxaparin BID or once daily dosing – Dalteparin once daily – Nadroparin BID dosing (not for use if wt >100kg) – Tinzaparin • Do not require monitoring in most cases
- 33. LMW Heparin vsUF Heparin • Compared with IV UFH LMW Heparin had – less mortality, – less thromboembolism – Less bleeding • Compared to SQ UFH – Similar outcomes
- 34. Fondaprinux • Subcutaneous administration •Similar outcomes when compared to IV UFH • Contraindicated in patients with severe renal failure
- 35. Warfarin • Started afteradministration of heparin (or heparin like agent) • Adjusted dose to INR 2.0-3.0
- 36. Duration of anticoagulation •First Episode – Reversible 3 months – Unprovoked indefinite (if bleeding risk acceptable) • Recurrent PE – Indefinite if risk of bleeding acceptable
- 37. New Anticoagulants- Rivaroxaban •Factor Xa Inhibitor • FDA approved for – non valvular A fib, – postop thromboprophylaxis hip and knee replacement – Treatment of DVT • Non inferior to Warfarin in Einstein PE study 2012 EINSTEIN-PE Study NEJM 2012
- 38. Rivaroxaban • Given as15mg PO dose BID for 3 weeks then 20mg daily • Doesn’t require monitoring • Good safety profile (less bleeding than with warfarin)
- 39. Dabigatran • Oral thrombin inhibitor • FDA approved for non valvular Atrial Fibrillation • Studied in Re-cover trial for DVT (not PE) • Non inferior to warfarin • Good safety profile Schulman et al NEJM 2009
- 40. Thrombolysis • Indications – Massive PE (SBP <90 for >15mins) • Controversial Indication – Severe hypoxemia – Large thrombus burden – RV dysfunction • ECG, Cardiac Enzyme Elevation, Echocardiography – RV thrombus in transit – Saddle Embolus
- 41. Contraindications • Absolute Contraindications – Intracranial neoplasm – Recent (<3 months) intracranial surgery or trauma – recent (<3 months) ischemic stroke – h/o hemorrhagic stroke – Active or recent bleeding
- 42. • Relative Contraindications – BP > 180 systolic – H/o ischemic stroke – Recent (<4 weeks) internal bleeding – Thrombocytopenia
- 43. Thrombolytic Agents • TissuePlasminogen Activator – tPA – Alteplase – IV drip 100mg over 2 hours • Streptokinase – IV drip 250,000 units over 30mins – Followed by 100,000u/hr for 24hrs • Urokinase
- 44. Side Effects ofthrombolysis • Bleeding (9%) – Intracranial hemorrhage (3%) • Allergic Reactions – Streptokinase • Hypotension - Streptokinase
- 45. Real Life Case • 52 yo male with cardiomyopathy (EF10%), • PH of DVT/PE in 2005, Gout • Presented with worsening shortness of breath • Has stable ET at 2-3 blocks • HR 69, BP 105/79 • 2/6 systolic murmur • Trace LE edema
- 47.
- 48. Before thrombolysis After thrombolysis
- 49. Surgical Embolectomy • ExperiencedSurgeon • Requires cardiopulmonary bypass • Indicated as an alternative to thrombolysis or when thrombolysis is contraindicated
- 51. Inferior Vena CavaFilter • “Filter out” large emobli from the pelvis, lower extremities • Inserted percutaneously • Indicated for patients who have contraindications to anticoagulation
- 52.
Editor's Notes
- #5 Prior to that he was feeling well, and his asthma was well controlled with fluticasone/salmeterol combination inhaler.
- #18 Sources: right heart, UE, renal, but most are from iliofemoral Most iliofemoral arise from calf veins, less often insitu Most calf VTE do not progress to iliofemoral
- #25 Patients with high clinical probability of PE and a high-probability V/Q scan had a 95% likelihood of having PE Patients with low clinical probability of PE and a low-probability V/Q scan had only a 4 percent likelihood of having PE A normal V/Q scan virtually excluded PE
- #27 Pneumonia, Aortic Dissection,
- #33 Exceptions include obesity, low body weight, renal insufficiency and pregnancy Level of antiXa should be checked 4hrs after administration
- #34 Once daily administration Less thrombocytopenia
- #37 Immobilization, surgery, trauma