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ISSUES IN TREATMENT OF ACUTE PULMONARY THROMBOEMBOLISM. Asc.Prof. SERHAT FINDIK, MD FCCP Ondokuz Mayis University Faculty of Medicine Department of Pulmonary Medicine. ACUTE PULMONARY THROMBOEMBOLISM. One of the most common causes of death Mortality without treatment : 30%
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ISSUES IN TREATMENT OF ACUTE PULMONARY THROMBOEMBOLISM Asc.Prof. SERHAT FINDIK, MD FCCP Ondokuz Mayis University Faculty of Medicine Department of Pulmonary Medicine
ACUTE PULMONARY THROMBOEMBOLISM • One of the most common causes of death • Mortality without treatment : 30% • Most of the deaths within first hours • Mortality with treatment : 2 – 8 %
ACUTE PULMONARY THROMBOEMBOLISM • Variable clinic picture asymptomatic – severe hipoxemia, right ventricular failure, shock, death • Treatment depends on clinical picture of the patient
PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment
ABSOLUTE CONTRAINDICATIONS ACTIVE MAJOR HEMORRHAGE • Intracranial hemorrhage • Retroperitoneal hemorrhage • Intrathoracic hemorrhage (lungs- pleura) • Hemorrhages causing > 2 gr / dL in hemoglobin
RELATIVE CONTRAINDICATIONS • Recent surgery (within two weeks) • Recent trauma (within two weeks) • Bleeding diathesis • Uncontrolled severe hypertension (systolic blood pressure > 200 mmHg, diastolic >120 mmHg) • Peptic ulcer
WELLS İNDEX POINT • Age > 65 1 • History of gastrointestinal bleeding 1 • Stroke 1 • At least one of the below ; 1 Hematocritet < %30 Creatinine > 1.5 mg/dl Diabetes mellitus Recent acute myocard infarction • Evaluation Low risk : 0 point, Moderate risk : 1 – 2 points High risk : ≥ 3 points
PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment
DIAGNOSTIC EVALUATION • DIAGNOSIS : PULMONARY THROMBOEMBOLISM • CONTRAINDICATION FOR ANTICOAGULATION
INDICATIONS • Contraindication for anticoagulation • Recurrent PTE despite anticoagulation • Major hemorrhage as a side effect of anticoagulation • Severe compromisement of pulmonary vascular bed such as massive PTE, CTEPH.
PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment
ANTICOAGULANT MUST BE GİVEN ? • Give in a patient with a high clinical risk for PTE • Mortalite without treatment is 30% • Risk for major hemorrhage is 3% • Patients with low – moderate clinical risk for PTE ? • Effectiveness of treatment depends on its effect within 24 hours
PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment
DIAGNOSTIC EVALUATION • DIAGNOSIS : PULMONARY THROMBOEMBOLISM
PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment
ACUTE PULMONARY THROMBOEMBOLISM • MASSIVE ? • SUBMASSIVE ?
MASSIVE PTE ? • Hemodynamic evaluation • Physical examination • ECG • Spiral CT pulmonary angiography • ECHO • Troponin / BNP • Arterial blood gases
HEMODYNAMIC EVALUATION • HYPOTENSION systolik blood pressure < 90 mmHg *, sudden decrease (at least 40 mmHg) in systolic blood pressure • TACHYCARDIA > 130 – 140 pulses / min • TACHYPNEA > 30 / min • SHOCK / COMA
PHYSICAL EXAMINATION • SIGNS FOR COR PULMONALE Prominence of neck veins Orthopnea Tachypnea Systolic murmur on tricuspid area(“Carvello maneuvre”) Prominence of S2 on pulmonary area Cyanosis
ELECTROCARDIOGRAPHY • Right ventricular strain pattern on anterior leads (V1-V4) • S1Q3T3 • Right bundle block • Right axis deviation • Tachycardia* • P pulmonale • Normal signs and / or nonspecific ST/T changes
SPIRAL CT PULMONARY ANGIOGRAPHY • Emboli burden • Pulmonary hypertension • Right ventricular dysfunction • Leftward shift of interventricular septum • Thrombus within right atrium or right ventricule • Patent foramen ovale • Thrombus within inferior vena cava
ECHOCARDIOGRAPHY • Dilatation of right ventricule • Leftward shift of interventricular septum • Decrease in ejection fraction (<%50) • Thrombus within right ventricule or right atrium • Pulmonary hypertension ( > 45-50 mmHg) • Patent foramen ovale
TROPONINE / BNP • High BNP, early mortality • Elevation of troponine increase mortality • Troponine I > 0.5 ng/mL in submassive PTE : Mortality within three months increases 3.5 times • Heart-type fatty acid binding protein (H-FABP)”
ARTERIAL BLOOD GASES • PaO2 < 60 mmHg • Sat O2 < %90 • Hypercapnia
PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment
ABSOLUTE CONTRAINDICATIONS • Active major hemorrhage • History of hemorrhagic stroke • Active intracranial neoplasm • Recent (within two months) intracranial surgery or trauma • Active (or within past 6 months) internal organ bleeding
RELATIVE CONTRAINDICATIONS • Bleeding diathesis • Uncontrolled severe hypertension (systolic blood pressure >200 mmHg, diastolic blood pressure > 120 mmHg) • History of nonhemorrhagic stroke within 2 months • Surgery within 10 days • Thrombocytopenia (100.000 / mm 3)
ABSOLUTE CONTRAINDICATIONS ACTIVE MAJOR HEMORRHAGE • Intracranial hemorrhage • Retroperitoneal hemorrhage • Intrathoracic hemorrhage (lungs- pleura) • Hemorrhages causing > 2 gr / dL in hemoglobin
PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment
THROMBOLYTIC DRUGS • STREPTOKINASE • UROKINASE • TISSUE TYPE PLASMINOGEN ACTIVATOR (TPA)
THROMBOLYTIC DRUGS • Plasminogen → Plasmine • Direct lyzis of thrombus