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Tuesday, November,10 ,2009

Outline. Overview on Pulmonary embolismStrategies of Management Thrombolytic therapyRecommendationSummary. Overview on Pulmonary embolism. Obstruction of the PA or one of its branches by material (eg, thrombus, tumor, air, or fat) Acute life-threatening but potentially reversible right ventricular failure.Incidence 600.000, 30% mortality.2-8% mortality with thrombolytic therapy.

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Tuesday, November,10 ,2009

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    2. Outline Overview on Pulmonary embolism Strategies of Management Thrombolytic therapy Recommendation Summary

    3. Overview on Pulmonary embolism Obstruction of the PA or one of its branches by material (eg, thrombus, tumor, air, or fat) Acute life-threatening but potentially reversible right ventricular failure. Incidence 600.000, 30% mortality. 2-8% mortality with thrombolytic therapy

    4. 65 to 90 % of (PE) arise from thrombi in the deep venous system of the lower extremities. Right heart or the pelvic, renal, or upper extremity veins

    6. Risk Factors *Where appropriate prophylaxis is used, relative risk is much lower. †Inflammatory bowel disease, nephrotic syndrome, chronic dialysis, myeloproliferative disorders, paroxysmal nocturnal haemoglobinuria, Behçet’s disease.*Where appropriate prophylaxis is used, relative risk is much lower. †Inflammatory bowel disease, nephrotic syndrome, chronic dialysis, myeloproliferative disorders, paroxysmal nocturnal haemoglobinuria, Behçet’s disease.

    8. Classification Acute Vs Chronic Massive or Submassive Massive PE causes hypotension, defined as a systolic blood pressure <90 mmHg or a drop in systolic blood pressure of =40 mmHg from baseline for a period >15 minutes Saddle pe :that lodges at the bifurcation of the main pulmonary artery into the right and left pulmonary arteried chronic PE tend to develop slowly progressive dyspnea over a period of years due to pulmonary hypertension Massive PE causes hypotension, defined as a systolic blood pressure <90 mmHg or a drop in systolic blood pressure of =40 mmHg from baseline for a period >15 minutes Saddle pe :that lodges at the bifurcation of the main pulmonary artery into the right and left pulmonary arteried chronic PE tend to develop slowly progressive dyspnea over a period of years due to pulmonary hypertension

    9. Massive PE 5% Thrombus occluding >50% of the pulmonary vasculature Hypotension SBP <90 mmHg or a drop in SBP of =40 mmHg of baseline for period >15 min. Neck vein distension due to elevated central venous pressure. Respiratory Distress

    10. Submissive PE 24-40% Normal Hemodynamics Signs & symptoms of RV dysfunction Saddle PE

    12. Presentation Extremely Variable Non-specific clinical presentation Both Sings & symptoms had low sensitivity and specificity

    13. SYMPTOMS Dyspnea at rest or with exertion (73 %), Pleuritic pain (44 %) cough (34 %) calf or thigh pain (44 %) calf or thigh swelling (41 %) wheezing (21 %) Hemoptysis ( 23%)

    14. SIGNS Tachypnea (54 %) Tachycardia HR > 100/min (30 %) Crackles (51 %) fever New Right sided heart failure Loud P2 and or right sided gallop Jugular venous distension (14 %)

    16. Clinical Assessment Of Pretest Probability Of Pulmonary Embolism Well’s score The revised Geneva score

    18.

    19. Risk Stratification Optimal diagnostic strategy and initial management. Clinical markers RV dysfunction markers Cardiac injury markers

    21. Intermediate-risk PE is diagnosed if at least one RVD or one myocardial injury marker is positive Low-risk PE is diagnosed when all checked RVD and myocardial injury markers are found negativIntermediate-risk PE is diagnosed if at least one RVD or one myocardial injury marker is positive Low-risk PE is diagnosed when all checked RVD and myocardial injury markers are found negativ

    22. Management Prevent propagation of the clot prevent recurrent VTE Pulm Hypertension

    23. Modalities of Management Anticoagulation therapy Vena caval Filters Thrombolytic Therapy Embolectomy

    24. Thrombolytic Therapy Rapid clot lysis improvement in pulmonary perfusion & cardiovascular function Eliminates venous thrombi Reducing risk of recurrent PE May prevent chronic vascular obstruction and persistent pulmonary HTN

    25. Controversial ….!!! Harm Vs Benefit

    29. Despite the lack of mortality benefit associated with thrombolytic therapy among pt with massive PE, still it is indication for thrombolysis because successful therapy can be lifesaving.

    30. Indication Massive PE Cardiac arrest in pt suspected PE Severe hypoxemia Large perfusion defect on V/Q Scan Extensive embolic burden CT Submissive PE with RV Dysfunction Free-floating right atrial or ventricular thrombus Patent foramen ovale

    31. Contraindications aContraindications to thrombolysis that are considered absolute, e.g. in acute myocardial infarction, might become relative in a patient with immediately life-threatening high-risk PE.aContraindications to thrombolysis that are considered absolute, e.g. in acute myocardial infarction, might become relative in a patient with immediately life-threatening high-risk PE.

    32. Approved Thrombolytic Agents Streptokinase: May cause Hypotension Urokinase rtPA

    33. Plasminogen Activator Italian Multicenter Study 2: 100 mg (rtPA) 12% decrease in vascular obstruction at the end of the 2 h infusion period. The USPE Trial : equal efficacy of urokinase and streptokinase infused over a period of 12–24 h. the Urokinase–Streptokinase Pulmonary Embolism Trial (USPET)the Urokinase–Streptokinase Pulmonary Embolism Trial (USPET)

    34. rtPA regimens showed better pulmonary flow at 2 hours but not subsequently compared with long and short regimens using the other agents Superiority of any thrombolytic agent or regimen over the others has not been definitively establishe

    35. Recommendations

    37. Summary The use of thrombolytic therapy in PE is Still controversial. Perform risk stratification on all Pt . Don’t delay thromblysis if it indicated Be ware of possible complication Evidence has failed to prove any deference between deferent types of thrombolytic agents

    38. References European Heart Journal (2008) Guidelines on the diagnosis and management of acute pulmonary embolism. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. American Journal of Emergency Medicine Fibrinolytic therapy in pulmonary embolism: an evidence-based treatment algorithm Brian T. Fengler MD, William J. Brady MD. Uptodate Chest –vol 135 Issue 5 May 2009 Thrombolytic Therapy for Acute Pulmonary Embolism Emergency Medicine Practice 2004 June Pulmonary Embolism: Remember That Patient You Saw Last Night?

    39. Thank You Questions

    40. Saddle PE :that lodges at the bifurcation of the main pulmonary artery

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