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t-PA 4 PE in ED

t-PA 4 PE in ED. Adrian Skinner ED registrar Auckland Hospital 28/11/02. Introduction. Case report Recent literature review Discussion of indications for thrombolysis in PE. Case Report Mr N.H. Presenting complaint 14/09/02 Increasing S.O.B. 3-4 days Chest Pains Several days.

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t-PA 4 PE in ED

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  1. t-PA 4 PE in ED Adrian Skinner ED registrar Auckland Hospital 28/11/02

  2. Introduction • Case report • Recent literature review • Discussion of indications for thrombolysis in PE

  3. Case Report Mr N.H. • Presenting complaint 14/09/02 • Increasing S.O.B. 3-4 days • Chest Pains Several days

  4. Recent History • 24 August • Admission Rapid AF • CXR : heart size upper limit of normal • Rx. Amiodarone • Appendicectomy : normal appendix • 9 September • Persistent cough • GP CXR normal

  5. Other Past History • Hyperlipidaemia • Rx. bezafibrate • NKDA

  6. Family History • Mother warfarinised in later life • ? reason

  7. Social History • Lives with wife • Retired commercial cleaner • Ex smoker (40 years ago) • Ethanol : 1 flagon beer/fortnight

  8. Examination • Temperature 34.2C (tympanic) • HR 140,HSDNM • RR 55, TML, normal breath sounds • BP 104/60 • Central cyanosis • O2 saturation 84% • Cool peripheries • Abdomen normal • No pedal oedema

  9. ECG

  10. ABG (oxygen 15L/min) • pH 7.42 • pO2 6.64 kPa • pCO2 3.03 • HCO3- 14.4 • BE -9.3 • Lactate 5.7 • sO2 84.7% • pO2 (A-a) = 9.94 kPa

  11. FBC and coagulation • Hb 158 • WCC 10.9 • Platelets 643 • INR 1.3 • APTT 27

  12. Biochemistry • Sodium 137 • Potassium 4.1 • Glucose 15.2 • Creatinine 0.16 • Troponin-T 0.18

  13. CXR • Lost at GLH • Looked OK to us • DCCM staff ? Oligaemic left lung field

  14. ECHO – trans-thoracic

  15. Treatment • High flow oxygen • IV fluid : 3 litres normal saline • Enoxaparin 80mg • Thrombolysis • t-PA 100mg over 2 hours front loaded

  16. Clinical progress • Rapid improvement towards completion of t-PA infusion • HR 110 • RR 20-30 • MAP 90 • O2 saturation 100% on high-flow oxygen • Transferred to DCCM via CT scanner

  17. ECG post t-PA

  18. CTPA

  19. Further progress • DCCM 1 day • Transferred to GLH respiratory medicine • Discharged day 7 • Repeat ECHO 1/10 RVSP 33mmHg + RAP • Haematology review 25/10 • Improving effort tolerance • Cardiology 4/11 • NSR 70/min normal effort tolerance • GP remains well

  20. ECG 4/11/02

  21. Acute Pulmonary Embolism • Clinical course and outcome dependent on • 1) Extent of pulmonary arterial obstruction • 2) Pre-existing cardiopulmonary disease • 2) Potential for recurrent thrombo-embolic events

  22. Mortality • All PE < 5% • PE with RV dysfunction 10-15% • PE with shock > 30%

  23. Prognostic value of Troponin-T • 56 Patients with confirmed PE • Graded as massive (n=17), moderate (n=26), small (n=13) • Troponin positive (> 0.1ng/ml) • 50%,50%,0% • In-hospital deaths (n=9) • Syncope OR 7.1 (1.2-33.3) • Shock OR 11.4 (2.1-63.4) • Troponin +ve OR 29.6 (CI 3.3-265.3) • Inotropes OR 37.6 (5.8-245.6) • Ventilation OR 78.8 (9.5-653.2) • Giannitsis et al Circulation 2000;102:211-217

  24. Giannitsis et al

  25. Thrombolysis for PE • Early trials from 1970’s • Small numbers • Multiple therapeutic regimens • Haemodynamically unstable patients excluded • Mortality in Haemodynamically stable patients @ 5-10%

  26. First RCT in massive PE • Streptokinase + Heparin ‘v’ Heparin only • Study stopped early after 8 enrolments • 4 streptokinase patients alive and well • Clinical improvement within 1 hour • 4 heparin-only all died • To date the only RCT in massive PE • Sanchez et al J Thromb Thrombolysis 1995;2(3):227-229

  27. PE + RV dysfunction • Grifoni et al Circulation 2000;101: 2817-2822

  28. PE with right ventricle dilatation • 128 patient monocentre registry 1992-1997 • Massive PE and RV dysfunction • No shock or hypotension • Thrombolysis ‘v’ heparin • Significant improvement in perfusion scan at 7 days with lysis • 4 deaths in lysis group • None in heparin group • Hamel et al CHEST 120; 1 July 2001 =: 120-125

  29. Massive PE + pulmonary hypertension or RV dysfunction • RCT (n=256) alteplase + heparin ‘v’ heparin • No hypotension or shock • Deaths 3.4% v 2.2% p=0.71 • Treatment escalation • 10.2% v 24.6% p=0.006 • Konstantinides et al NEJM 347, No.15;10 Oct 2002: 1143-1150

  30. Conclusions • Patients with massive PE benefit from thrombolysis • Current research suggests that there may be a subgroup of those with evidence of RV dysfunction who will benefit from thrombolysis • Further research required to determine this group • Trans thoracic ECHO is an important part of initial evaluation

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