2. DEFINITION:
PULMONARY EMBOLISM ( PULMONARY THROMBOEMBOLISM –PTE)
AN EMBOLISM IN WHICH EMBOLI OCCLUDE PULMONARY TREE (PULMONARY ARTERY
OR ITS BRANCHES).
PULMONARY INFARCTION
ISCHEMIC NECROSIS OF LUNG TISSUE FOLLOWING EMBOLIC OCCLUSION
3. EPIDEMIOLOGY:
INCIDENCE : 1.5 PER 1000 PERSON-YEARs
2ND MOST COMMON CAUSE OF UNEXPECTED DEATH
15% OF ALL POST OP DEATHS
60-80% OF PATIENTS WITH DVT
> 50% ASYMPTOMATIC
*REF-BRAUNWALD’S TEXTBOOK OF CARDIOLOGY 12TH EDITION PAGE NO 1680
8. PROTHROMBOTIC STATES:
DEFICIENCY OF ANTITHROMBOTICS
- ANTI-THROMBIN III DEFICIENCY, PROTEIN C AND S DEFICIENCY
INCREASED PROTHROMBOTIC FACTORS
- FACTOR V AND FACTOR V LEIDEN MUTATION
- ACTIVATED PROTEIN C RESISTANCE
19. INVESTIGATIONS :
ECG – SINUS TACHYCARDIA,
RV STRAIN AND ISCHEMIA (M/C ), RIGHT AXIS DEVIATION, RBBB PATTERN, RIGHT
ATRIAL ENLARGEMENT (TALL P)
T INVERSION V1 TO V4.
S1Q3T3 OR S1Q3- RELATIVELY SPECIFIC BUT INSENSITIVE.
24. BLOOD INVESTIGATIONS :
PLASMA D-DIMER ASSAY : SCREENING TEST RELIES ON THE PRINCIPLE THAT MOST
PATIENTS WITH PE HAVE ONGOING ENDOGENOUS FIBRINOLYSIS THAT IS
NOT EFFECTIVE ENOUIGH TO PREVENT PE, BUT THAT BREAKS SOME OF
THE FIBRIN CLOT TO D-DIMERS.
25. D-DIMER:
>95% SENSITIVE BUT NOT SPECIFIC.
A NORMAL D-dimer rule out PE.
LEVELS INCREASES IN PATIENT WITH MI,PNEUMONIA,SEPSIS,CANCER POST OP.
STATES, 2ND AND 3RD TRIMESTER PREGNANCY.
THEREFORE D-dimer RARELY HAS A USEFUL ROLE AMONG HOSPITALIZED
PATIENT, BECAUSE LEVELS ARE FREQUENTLY ELEVATED DUE TO SYSTEMIC
ILLNESS.
26. CARDIAC BIOMARKERS – RASIED SERUM TROPONIN, RAISED BNP AND NT-PRO-
BNP
ABG- RESPIRATORY ALKALOSIS, HYPOXIA,TYPE I RF.
30. OTHERS:
VQ- LUNG SCAN: IN PATIENT WITH RENAL INSUFICIENCY, ALLERGIC TO
CONTRAST, PREGNANCY AND WHERE CT IS CONTRAINDICATED.
MR ANGIO
INVASIVE CONVENTIONAL PULMONARY ANGIOGRAM
VENOUS ULTRASONOGRAPGY : FOR DIAGNOSIS DVT.
31. WELLS CRITERIA :
CLASSICAL WELLS CRITERIA SIMPLIFIED WELLS CRITERIA
DVT SYMPTOMS OR SIGNS 3 1
AN ALTERNATIVE DIAGNOSIS IS
LESS LIKELY THAN PE
3 1
HR >100/MIN 1.5 1
IMMOBILIZATION OR SURGERY
WITHIN 4 WEEKS
1.5 1
PRIOR DVT OR PE 1.5 1
HEMOPTYSIS 1 1
CANCER TREATED WITHIN 6
MONTHS OR METASTATIC
1 1
>4 HIGH PROBABILTY
<= 4 UNLIKELY
>1 HIGH PROBABILITY
<=1 UNLIKELY
33. TREATMENT :
STEP 1 RISK STRATIFICATION AND STABILISATION OF IF HEMODYNAMICALLY
UNSTABLE.
IVF NS/RL
AVOID DIURETICS AND VASODILATORS BECAUSE THEY WILL FURTHER REDUCE
CO.
VASOPRESSORS
AIRWAY
ANALGESICS
PARENTERAL ANTICOAGULATION
ECMO- EXTRA CORPOREAL MEMBRANE OXYGENATION.
34. PULMONARY EMBOLISM SEVERITY
INDEX(PESI):
PREDICTOR SCORE POINTS
AGE,PER YEAR AGE IN YEARS
MALE SEX 10
HISTORY OF CANCER 30
H/O HEART FAILURE 10
H/O CHRONIC LUNG DISEASE 10
HR >110/MIN 20
SYSTOLIC BP <100 30
RESPIRATORY RATE >=30/MIN 20
TEMPERATURE <36 F 20
ALTERED MENTAL STATUS 60
ARTERIAL OXYGEN SATURATION <90% 20
35. RISK CATEGORY BASED ON PESI SCORE:
BASED ON TOTAL POINT SCORE
CLASS I <65
CLASS II 66-85
CLASS III 86-105
CLASS IV 106-125
CLASS V > 125
CLASS I & II CONSIDERED LOW RISK
CLASS III,IV & V HIGH RISK CATEGORY
36. ACUTE PE
RISK STRATIFICATION
CLINICAL EVALUATION,ANATOMICAL
EXTENT OF PE,RV
SIZE/FUNCTION,CARDIAC BIOMARKERS
HIGH RISK
LOW RISK
ANTICOAGULATION ALONE
THROMBOLYSIS OR
EMBOLECTOMY PLUS
ANTICOAGULATION
MANAGEMENT STRATIGY:
37. IV THROMBOLYSIS :
INDICATIONS:
1. HEMODYNAMIC INSTABILTY
2. HYPOXIA WITH 100% O2
3. RIGHT VENTRICULAR DYSFUNTION.
38. BENEFITS OF IV THROMBOLYSIS
ACCLELERATED CLOT LYSIS AND PERFUSION
DECRESED MORLATILTY
REVERSAL OF RIGHT HEART FAILURE
DECREASED RECURRENCE
DECREASED PULMONARY HTN AND CTEPH
GREATEST BENEFITS IF DONE WITHIN 48HOURS
CAN BE DONE UPTO 14 DAYS.
39. CONTRAINDICATIONS
ABSOLUTE – ACTIVE INTERNAL BLEEDING
(MENSTURATION NOT A CONTRAINDICATION)
RELATIVE-(RISK BENEFIT)
RECENT SURGERY, HTN (>200/110 MMHG),BLEEDING DISORDERS.
40. IV THROMBOLYTIC REGIMENS FOR PE
ALTEPLASE – 100MG OVER 2 HRS
UROKINASE- 4400U/KG OVER 10 MIN F/B 4400U/KG/HR OVER 12-24HRS.
STREPTOKINASE- 2,50,000 U OVER 30 MIN F/B 1,00,000 U /HR OVER 12-24
HRS.
41. WHERE BLEEDING RISK IS HIGH
HALF DOSE THROMBOLYSIS *
CATHER DIRECTED THROMBOLYSIS.
*REF-HARRISION 21ST EDITION PAGE NO-2100
42. ANTICOAGULATION :
LMWN (ENOXAPARIN STANDARD DOSE 0.6 BID)
UFH – 80 U/KG F/B 18U/KG/HR , MONITOR APPT TARGET 60-80 SEC.
FONDAPARINUX WEIGHT BASED
50 TO 100 KG 5-7MG S/C OD
<50 KG – 5MG S/C OD
> 100 KG – 10 MG S/C OD
45. DURATION OF ANTICOAGULATION :
THERAPEUTIC ANTICOAGULATION IS MANDATORY FOR 3 TO 6 MONTHS ALL
PATIENT WITH 1ST EPISODE OF VTE WITH REVERSIBLE RISK FACTORS (e .g -
PREGNANCY,TRAUMA)
PROLONGED/ LIFE LONG ANTICOAGULATION IS REQUIRED RECURRENT
(>1EPISODE),UNPROVOKED 1ST EPISODE AND PATIENT WITH MALIGNACY.
48. PREVENTION AND PROPHYLAXIS FOR
VTE:
ANTICOAGULATION PROPHYLAXIS
GRADUATED COMPRESSION STOCKINGS OR INTERMITTENT PNEUMATIC
COMPRESSION.
COMBINATION OF PHARMACOLOGICAL AND MECHANICAL PROPHYLAXIS IS THE
BEST APPROACH.
LOWER EXTREMITY VENOUS ULTRASONOGRAPHY SURVEILLANCE.
49. CHRONIC THROMBOEMBOLIC
PULMONARY HYPERTENSION(CTEPH):
CTEPH DEVELOPS IN 2-4% OF PATIENT OF ACUTE PE PATIENTS.
MANAGEMENT
PULMONARY THROMBOENDARTERECTOMY, LIFELONG ORAL ANTICOGULANT AND
REDUCTION OF PULMONARY HYPERTENSION (EDOTHELIN ANTAGONIST-
BOSENTAN,MACITANTAN; PDE5 INHIBITORS –SILDENAFIL,TADALAFIL;POSTACYCLIN
ANALOGS-ILOPROST)