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PULMONARY EMBOLI

PULMONARY EMBOLI. Kenney Weinmeister M.D. PULMONARY EMBOLI. Over 500,000 cases per year. Results in 200,000 deaths. Mortality without treatment is 30%. With therapy mortality drops to 2-8%. RISK FACTORS FOR THROMBOEMBOLIC DISEASE. Obesity has an increased risk factor of 2.9. Tobacco use:

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PULMONARY EMBOLI

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  1. PULMONARY EMBOLI Kenney Weinmeister M.D.

  2. PULMONARY EMBOLI • Over 500,000 cases per year. • Results in 200,000 deaths. • Mortality without treatment is 30%. • With therapy mortality drops to 2-8%.

  3. RISK FACTORS FOR THROMBOEMBOLIC DISEASE • Obesity has an increased risk factor of 2.9. • Tobacco use: • 25-35 cigarettes/day risk factor is 1.9. • >35 cigarettes/day risk factor is 3.3. • Hypertension caries a risk factor of 1.9. • Factor V Leiden mutant is seen in 40% of idiopathic thromboembolic disease.

  4. Tachypnea 70% Rales 51% Tachycardia 30% S4 24% Accentuated P2 23% Dyspnea 73% Pleuritic Chest Pain 66% Cough 37% Hemoptysis 13% Signs And Symptoms

  5. MASSIVE PE DEFENITION • Systolic BP less than 90 mmHg • Drop in systolic BP of > 40 mmHg from baseline for > 15 minutes, not explained by hypovolemia, sepsis, or a new arrhythmia • Two or more lobar arterial occlusions Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J 2000

  6. MASSIVE PE PATHOPHYSIOLOGY • Increased afterload on right ventricle • Occlusion of vascular bed • Vasoconstriction • Elevated pulmonary artery pressure • 50% obstruction before mean PAP rises • Right ventricle fails • 75% obstruction of vascular bed • Death

  7. DIAGNOSIS • ECG • ABG • CHEST X-RAY • D-dimer: • ELISA method D-dimer < 500ng/ml has a negative predictive value of 95 to 99%. • Turbidimetric D-dimer

  8. D-dimer • Unidirectional. • A negative quantitative rapid ELISA result is as diagnostically useful as a normal V/Q scan or negative venous dopplers. • Unlikely to be helpful in patients with recent surgery (within three months) or with malignancy.

  9. ECHOCARDIOGRAPHY • RV dysfunction • Mobile cardiac emboli were seen in 18% of 130 patients with massive PE • Prospective study of 317 pts, 27% had RV dysfunction on Echo. Mortality with RV dysfunction 13%, without 0.9% • Heart 1997

  10. DIAGNOSIS: Ventilation Perfusion Scan • High probability: • > 2 Large segmental defects • > 2 Moderate segmental defects with 1 Large • > 4 Moderate segmental defects • Intermediate probability: not falling into low or high probability.

  11. DIAGNOSIS: Ventilation Perfusion Scan • Low probability: • Nonsegmental perfusion defects. • Single moderate mismatched segmental perfusion defect with normal cxr. • Large or moderate segmental defects with matching defects. • > 3 small segmental perfusion defects. • Normal: no perfusion defects.

  12. Venous Doppler • B-Mode compression ultrasound: • 6 level one studies; • Sensitivity 89 - 100% • Specificity 86 - 100% • Positive Predictive Value 92 - 100% • Negative Predictive Value 75 - 100% • Duplex US and Color flow doppler US have similar results.

  13. PULMONARY ANGIOGRAPHY • Gold standard. • Mortality 0.2 - 0.5% • Morbidity 1 - 4%

  14. SPIRAL COMPUTED TOMOGRAPHY • Greatest sensitivity for emboli in the main, lobar or segmental pulmonary arteries. • Only level 2 studies which show: • Sensitivity 60 -100% • Specificity 78 - 97%

  15. Spiral Computed Tomography • 1041 patients, anticoagulation withheld for negative CTA and dopplers. 360 (34%) dx with PE. 55 had + dopplers and negative CTA. 76 pts high probability PE but negative CTA & dopplers 4 had + V/Q or PAG. 507 not treated, 9 (1.8%) had TED at f/u. Lancet 2002 Dec 14;360(9349):1914-1920

  16. Spiral Computed Tomography • 548 pts negative or low probability V/Q or negative CTA. PE found in 2 (1%) of 198 pts with neg CTA, 0 pts of 188 with neg V/Q, and five (3%) of 162 pts with low prob V/Q. Radiology 2000 May;215(2):535-42

  17. TREATMENT • Anticoagulation • Thrombolitics • IVC filter • Thrombectomy • Catheter • Surgery

  18. ANTICOAGULANTS • Heparin • Low molecular weight heparin • Direct thrombin inhibitors • Factor Xa inhibitors • Coumadin

  19. HEPARINS • Heparin • dose on weight base • LMWH • Some trials illustrate safety and efficacy of outpatient therapy or initiation of in hospital use and discharge on coumadin and LMWH.

  20. Direct Thrombin Inhibitors • Hirudin • Lepirudin • Argatroban • Ximelagatran • Bivalirudin

  21. Factor Xa Inhibitors • Fondaparinux • Razaxaban

  22. First event, age < 60 First event, age > 60 or idiopathic disease Recurrent event or first event with a nonreversible risk factor 3-6 months 6-12 months 12 months to lifetime DURATION OF THERAPY BY RISK FOR RECURRENCE

  23. INFERIOR VENA CAVA FILTER • No large studies have been performed to evaluate the impact on recurrence of PE. • No large prospective studies have been performed with regards to safety and efficacy. • Mortality 0.1 to 0.2% • Morbidity up to 18% risk of thrombosed IVC.

  24. CONCLUSION • The diagnosis of PE is difficult and cannot be made on clinical criteria. • Large clinical trials are needed to evaluate the new imaging techniques as well as new diagnostic tests. • Failure to diagnose continues to be one of the largest causes of malpractice claims.

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