Prior to that he was feeling well, and his asthma was well controlled with fluticasone/salmeterol combination inhaler.
Sources: right heart, UE, renal, but most are from iliofemoral Most iliofemoral arise from calf veins, less often insitu Most calf VTE do not progress to iliofemoral
Patients with high clinical probability of PE and a high-probability V/Q scan had a 95% likelihood of having PE Patients with low clinical probability of PE and a low-probability V/Q scan had only a 4 percent likelihood of having PE A normal V/Q scan virtually excluded PE
Pneumonia, Aortic Dissection,
Exceptions include obesity, low body weight, renal insufficiency and pregnancy Level of antiXa should be checked 4hrs after administration
Once daily administration Less thrombocytopenia
Immobilization, surgery, trauma
Pulmonary Embolism Salah Abusin, MD, MRCP Cardiology Fellow Chicago, IL Secretary GeneralSudanese American Medical Association
History• A 61 year old male – New onset shortness of breath for 4 days. – He also noticed a cough, with blood tinged sputum. – He had no chest pain, no orthopnea or paroxysmal nocturnal dyspnea, or fever. – He used his albuterol inhaler several times with no improvement in his shortness of breath• .
• Past history: – Hypertension – Asthma – Remote history (10 years prior to current presentation) of left lower limb swelling that subsided after treatment for 6 months.• Social history: Smoker 40 pack year history• Family history: no relevant family history.• Drug history: – fluticasone/Salmeterol combination inhaler twice daily, – albuterol inhaler as needed for shortness of breath – hydrochlorothiazide 12.5mg once daily
Physical Examination:• Vital Signs: – HR 113/min, – BP 150/93, – respiratory rate 22/min, – oxygen saturation via pulse oximetry 89% on room air, – temperature 97.2° F (36.2 °C)
• HEENT: (Head, Eyes, Ear, Nose, Throat examination) was normal.• JVP was not raised.• Chest clear no wheezes, or crackles.• Abdomen soft non tender, no palpable liver, spleen.• Lower extremities: no edema, no other abnormalities• PEFR (peak expiratory flow rate) was above 75% of predicted
What is your differential diagnosis?What test would you like to perform next?
Investigations• Chest X ray Clear Lung fields• ECG Sinus Tachycardia• Basic metabolic panel (BMP) includes Na, K, HCO3, Chloride, BUN, Creatinine was within normal limits.• Complete blood count: Hb 15.9, WBC 7200 with normal differential, platelet count 270.• Liver function test, and liver enzymes were within normal limits.
Arterial Blood Gas on Room Air• pH 7.42 (normal)• pCO2 33.2 (mildly reduced)• pO2 55 (moderately reduced)• Oxsat 87%
Types• Acute – Massive (BP <90/40 >15mins) – Submassive – doesn’t meet above definition• Chronic• Saddle PE – Embolus lodges at the Main PA bifurcation
Natural History• 30% die if untreated• Usually due to recurrent PE
Symptoms• Dyspnea at rest or with exertion (73%)• Pleuritic pain (44 %),• calf or thigh pain (44%),• calf or thigh swelling (41%),• cough (34%),• >2-pillow orthopnea (28% ),• wheezing (21 %) PIOPED II. Stein PD , Beemath A et al Am J Med. 2007;120(10):871.
Signs• tachypnea (54%),• tachycardia (24%),• crackles (18%),• decreased breath sounds (17%),• Loud S2 (15%),• Raised JVP (14 %) PIOPED II. Stein PD , Beemath A et al Am J Med. 2007;120(10):871.
Laboratory Investigations• ABGs – Hypoxemia – Hypocapnia – Respiratory alkalosis – Hypercapnia, Resp acidosis (if massive) – Metabolic acidosis (if massive)• Troponin – Elevated in moderate to severe PE
D dimer• Fibrin degradation product• Is elevated in most patients with PE• High negative predictive value• i.e. useful to rule out PE in patients with low to intermediate pretest probability
ECG• Sinus tachycardia• Non specific ST/T changes• Classical findings are uncommon – S1Q3T3 pattern, – RV strain, – new incomplete RBBB
Chest Xray• Usually abnormal but doesn’t differentiate PE from other diagnoses PE No PE Atelectasis or a pulmonary 69% 58% parenchymal abnormality Pleural Effusion 47% 39% Normal 12% Stein et al Chest. 1991;100(3):598
VQ Scan• Interpreted as probability i.e. – Low Probability – Intermediate Probability – High Probability• Diagnosis of PE using VQ scan requires integration of the pretest probability• Normal VQ Scan virtually excludes PE
CT Chest• Advantages – High Specificity for main, lobar and segmetal vessels – Rapidity – Diagnosis of other disease entities• Disadvantages – Availability – Expense – Less sensitivity with subsegmental vessels – Contrast Load
Diagnosis• Clinical findings are generally non specific, variable, and common with other conditions• Results of Diagnostic Investigations (VQ, CT) have to be integrated with the pretest probability of PE
Unfractionated Heparin• Proven to work since 1960• Intravenous – Bolus of 80u/kg followed by infusion at 18u/kg/hr – Titrate to target PTT 1.5-2.5x the control aPTT• Subcutaneous – After IV bolus of 5000u, 250u/kg BID – SQ bolus of 333u/kg – aPTT Not monitored
LMW Heparin• Administered subcutaneously• Examples include – Enoxaparin BID or once daily dosing – Dalteparin once daily – Nadroparin BID dosing (not for use if wt >100kg) – Tinzaparin• Do not require monitoring in most cases
LMW Heparin vs UF Heparin• Compared with IV UFH LMW Heparin had – less mortality, – less thromboembolism – Less bleeding• Compared to SQ UFH – Similar outcomes
Fondaprinux• Subcutaneous administration• Similar outcomes when compared to IV UFH• Contraindicated in patients with severe renal failure
Warfarin• Started after administration of heparin (or heparin like agent)• Adjusted dose to INR 2.0-3.0
Duration of anticoagulation• First Episode – Reversible 3 months – Unprovoked indefinite (if bleeding risk acceptable)• Recurrent PE – Indefinite if risk of bleeding acceptable
New Anticoagulants- Rivaroxaban• Factor Xa Inhibitor• FDA approved for – non valvular A fib, – postop thromboprophylaxis hip and knee replacement – Treatment of DVT• Non inferior to Warfarin in Einstein PE study 2012 EINSTEIN-PE Study NEJM 2012
Rivaroxaban• Given as 15mg PO dose BID for 3 weeks then 20mg daily• Doesn’t require monitoring• Good safety profile (less bleeding than with warfarin)
Dabigatran• Oral thrombin inhibitor• FDA approved for non valvular Atrial Fibrillation• Studied in Re-cover trial for DVT (not PE)• Non inferior to warfarin• Good safety profile Schulman et al NEJM 2009
Thrombolysis• Indications – Massive PE (SBP <90 for >15mins)• Controversial Indication – Severe hypoxemia – Large thrombus burden – RV dysfunction • ECG, Cardiac Enzyme Elevation, Echocardiography – RV thrombus in transit – Saddle Embolus
Contraindications• Absolute Contraindications – Intracranial neoplasm – Recent (<3 months) intracranial surgery or trauma – recent (<3 months) ischemic stroke – h/o hemorrhagic stroke – Active or recent bleeding
Thrombolytic Agents• Tissue Plasminogen Activator – tPA – Alteplase – IV drip 100mg over 2 hours• Streptokinase – IV drip 250,000 units over 30mins – Followed by 100,000u/hr for 24hrs• Urokinase
Side Effects of thrombolysis• Bleeding (9%) – Intracranial hemorrhage (3%)• Allergic Reactions – Streptokinase• Hypotension - Streptokinase
Real Life Case• 52 yo male with cardiomyopathy (EF10%),• PH of DVT/PE in 2005, Gout• Presented with worsening shortness of breath• Has stable ET at 2-3 blocks• HR 69, BP 105/79• 2/6 systolic murmur• Trace LE edema