- Pulmonary embolism (PE) is the third most common acute cardiovascular syndrome after myocardial infarction and stroke. - PE presents with symptoms like dyspnea, chest pain, cough, hemoptysis, tachycardia, edema and signs like murmurs and cyanosis. Diagnosis is confirmed with tests like CTPA, ECG, blood tests. - Management involves ICU admission, intravenous access, monitoring, oxygen supplementation, inotropes if unstable, thrombolysis if unstable, anticoagulation with heparin or LMWH initially then switched to vitamin K antagonists or NOACs long term. Other options include catheter directed thrombolysis, surgical embolectomy

1. Significance
• Venous thromboembolism (VTE),
clinically presenting as DVT or PE third
most frequent acute cardiovascular
syndrome behind myocardial infarction
and stroke.

2. TYPES

6. PRESENTATION
• Dyspnoea
• Pleuritic chest pain
• Cough
• Hemoptysis
• Tachycardia
• Accentuated S2,S3, S4
gallop
• Fever
• Thrombophlebitis
• LL edema
• Murmur
• cyanosis
Hemodynamic instability

8. • ECG
• Sinus tachycardia
• Complete or incomplete RBBB (18%)
• Right ventricular strain pattern – T wave inversions in
the right precordial leads (V1-4) ± the inferior leads (II,
III, aVF). This pattern is associated with high pulmonary
artery pressures (34%)
• Right axis deviation (16%). Dominant R wave in V1 – a
manifestation of acute right ventricular dilatation
• P pulmonale – peaked P wave in lead II > 2.5 mm in
height (9%)
• SI QIII TIII pattern
• Atrial tachyarrhythmias – AF, flutter, atrial tachycardia
(8%)

12. Good quality CTPA.
Extensive right sided segmental and subsegmental (to upper, middle and
lower lobes) pulmonary arterial filling defects in keeping with acute
pulmonary emboli.
Bilateral minimal pleural effusion, with bibasal atelectesis.
.

18. MANAGEMENT
• Icu admission-Continuous monitoring of ECG,
BP, SPO2,
• Wide bore iv cannula
• A, B , C
• Avoid large volume fluid resuscitation.
• Low threshold for inotropes.
• Severe hypoxia/ resp distress- intubate and
ventilation with lung proetective strategies

19. • Hemodynamically unstable- thrombolysis.
STREPTOKINASE UROKINASE ALTEPLASE TENECTAPLASE
GENERATION 1st 1st 2nd 3rd
CLOT SPECIFIC no no yes yes
HALF LIFE(min) 12 7-20 4-10 15-24
DOSAGE 250,000U iv over
0.5hr –
100,000U/hr for
24hrs
4400u/kg
over 10mins
–
4400u/kg/hr
for 12hrs
100mg over
2hrs
<60kg=30mg
60-70kg=35mg
70-80kg=40mg
80-90kg=45mg
>90kg=50mg
FDA
APPROVED
yes yes yes no

20. • Empiric anticoagulation started in all proven/
suspected PE: UFH/ LMWH
• After initial therapeutic anticoagulation ->
switched to vitK antagonists/ NOAC

23. OTHER ALTERNATIVES
TECHNIQUE MECHANISM ADVANTAGE DISADVANTAGE
CATHETER
DIRECTED
THROMBOLYSIS
Direct
administration of
low dose
therapeutic agent
into clot
Low dose required.
Effective for distal
clots. Patients with
RV dysfunction/ at
high risk of
bleeding/
hemodynamically
unstable- benefit
from this
High chance of
bleeding
USG ASSISTED
THROMBOLYSIS
Catheter directed
high frequency USG
used to break the
clot and
simultaneously
administer local
thrombolysis
Lower dose of
thrombolytic when
compared to above
cost

24. INARI FlowTriever and its components. The 20
F aspiration guide catheter (a), the proprietary
syringe (b) (black arrows) and nitinol discs, (c)
(black arrows) engaging the clot

25. • Surgical embolectomy: performed in cases
when thrombolysis has failed/ those in whom
it is contraindicated.
• High mortality
• Complications: surgery related, perforation of
pulmonary artery.

26. VENA CAVAL FILTERS
• Recommended only if there is C/I to
anticoagulation Rx in pts
with PE/ proximal DVT.

27. Recommendations
• Therapeutic anticoagulation for >_ 3 months is
recommended for all patients with PE.
• Patients in whom discontinuation of
anticoagulation after 3 months is
recommended :For patients with first PE/VTE
secondary to a major transient/reversible risk
factor, discontinuation of therapeutic oral
anticoagulation is recommended after 3
months.

28. • Oral anticoagulant treatment of indefinite duration is
recommended for patients presenting with recurrent
VTE (that is, with at least one previous episode of PE or
DVT) not related to a major transient or reversible risk
factor
• For patients with PE and cancer, weight-adjusted
subcutaneous LMWH should be considered for the first
6 months over VKAs
• For patients with PE and cancer, extended
anticoagulation (beyond the first 6 months)c should be
considered for an indefinite period or until the cancer
is cured

30. • LMWH is the treatment of choice for PE during
pregnancy.
• LMWH does not cross the placenta, and
consequently does not confer a risk of foetal
haemorrhage or teratogenicity.
• LMWH has more predictable pharmacokinetics.
• Anticoagulant treatment should be administered
for >_6 weeks after delivery and with a minimum
overall treatment duration of 3 months.
• LMWH and warfarin can be given to
breastfeeding mothers; the use of NOACs is not
recommended