4. PE treatment (including high risk PE)
• Respiratory and hemodynamic support
• Anticoagulation
• Trombolytic treatment
• Percutaneous intervention
• Surgical trombectomy
5. Anticoagulation
• Anticoagulation treatment plays a pivotal role in the
management of patients with PE
• Initial anticoagulation should be introduce
immediately
• Potential options:
- UFH
- LMWH (dalteparin, enoxaparin, nodraparin)
- Fondaparynuks
- Riwaroksaban
- other
7. Anticoagulation
• In massive PE with hemodynamic consequences or a
shock - anticoagulation with UFH
• LMWH should be given in care in pts with renal
failure
• Due to high mortality rate in untreated pts
anticoagulation should be considered when PE is
strongly suspected: awaiting for definite dgn
confirmation
• Duration depends on many factors (PE etiology,
transient risk factors, cancer coexistence,etc.)
BLEEDING RISK
8. Thrombolyitic regimens for PE
• rtPA
- standard: 100 mg i.v. (2 h)
- fast regimen: 0,6 mg/kg (max. 50 mg) during 15 min
• Streptokinase
- fast regimen: 1,5 mln j.m. units i.v. (2h)
- standard: 250 000 j.m. within 30 min, followed by 100
000 jm/h within 12-24 h
• Urokinase
- fast regimen: 3 mln j.m. i.v. within 2 h
- standard: 4400 j.m./kg within 10 min, followed by 4400
j.m./h within 12-24 h
9. Specifity of lungs circulation
• Exquisitely sensitive to lysis
• Point of convergence of venous circulation
• Pulmonary blood flow = entire CO (Cardiac Output)
• In comparison: brain 15 % of CO, heart 5 % of CO
• Repeated „hits” of tPA by recirculation
10. Combined pharmacological
approach
• Safe dose thrombolysis
• Modified and short dose of heparin
• New oral anticoagulants
• 98 pts with moderate and severe PE
• O mortality rate in hospital, bleeding 0 in hospital
• Low adverse events in follow-up
Sharifi et al. Clin Card 10/2013
11. Other therapautic options for PE
• Surgical pulmonary embolectomy
• Percutaneous catheter embolectomy and
fragmentation
- When contraindications for fibrynolytic therapy
- Fibrynolytic therapy failed
! Only if:
• applicable technical condition available
• experienced interventional team
12. Other therapautic options for PE
Vena Cava Filters
• Ideally the retrievable variety of device
• When contraindication to anticaogaulation (eg. Recent
--- hemorrhage
• - impending surgery
14. Conclusions
• PE is common, potential live threatening condition
• In hospital mortality rate up to 12 % (US)
• Aggressive pharmacological - interventional
treatment is effective in majority of cases
• Farther diagnosis of possible PE causes is
mandatory (deep vein thrombosis, cancer, other)
• Is one of more frequent comorbiditie in patients
hospitalized from other reason.
