2. CTA official read Lungs: There is infiltrate or atelectasis in the right lung base. Pulmonary vessels: There is a large saddle-like embolus in the left main pulmonary artery extending into the upper and lower lobe branches. There are emboli identified in the right lower lobe pulmonary arteries. Pleural: There is a possible small right pleural effusion Heart and pericardium: Normal Chest wall: normal. ** IMPRESSION **: Extensive bilateral pulmonary emboli. Right lung infiltrate versus atelectasis.
25. AACP Guidelines for long term treatment of acute PE Provoked PE=> 3 months anticoagulation Unprovoked PE => at least 3 months , then evaluate risk-benefit ratio of long-term therapy First unprovoked PE with low bleed risk => long-term therapy Second unprovoked VTE => long-term therapy Unprovoked PE + desire for less frequent INR testing => INR goal 1.5-1.9 after 3 months of INR 2-3 Chest 2008;133;71S-109S
26. Risk benefit ratio Cumulative VTE recurrence after completion of anticoagulation: 26.3% by 3 years after idiopathic VTE 12.3 % by 3 years after provoked VTE Case-fatality rate 9% for recurrent VTE (idiopathic PE) after discontinuation of anticoagulation Case-fatality of major bleeding 13.4%, but decreases to 9% after 3 months Haematologica, Vol 92, Issue 2, 199-205 Ann Intern Med. 2007;147:766–774 Ann Intern Med. 2003;139:893–900
27. Factors associated with recurrence Persistently elevated ddimer Male gender (under age 60) Idiopathic etiology Obesity Hematology Am Soc Hematol Educ Program. 2008:252-8.
35. DVTs found in 4.8% of control, 3.6% of ASA group, 0.6% enoxaparin group
36. 85% of DVTs occurred in people with non-aisle seats! Angiology 2002;53:1-6.
37. What would you do? A) Stop coumadin B) Continue coumadin for life C) Stop coumadin but use lovenox prn travel
38. Take home points Once dx of PE is made => risk stratify Look for underlying etiologies Regularly review risk benefit ratio of anticoagulation for individual patient THANK YOU!
Editor's Notes
ICU vs. MSTTPA vs. heparin gttMcConnell's sign. This is the finding of akinesia of the mid-free wall but normal motion of the apex. This phenomenon has a 77% sensitivity and a 94% specificity
“Massive PE” = cardiogenic shock“Submassive PE” = HDS with e/o RV strainTPA if no CI Otherwise, embolectomy w/in 5 daysLong term mgmtProvoked vs. unprovoked
The most important question that will determine long-term management is deciding on provoked vs. unprovoked etiology**Protein C, S, Antithrombin III affected by acute thrombotic event and anticoagulation APC resistance (F5L, PT, natural anticoagulants) – inherited F5L – autosomal dominant mutation creates a factor 5 that is resistant to inactivation be activated protein C (92% of APC resistance), most common abnormality found in familial hypercoagulability (usually sent along with PT20210 in our lab)Prothrombin (factor 2) G20210 – autosomal dominant, single point mutation, increases levels of factor IINatural anticoagulant proteins – ATIII, protein C/SAPA – acquiredOther acquired hypercoagulable states – malignancy, pregnancy, OCPs, hormonal APS – thrombotic phenomenon or pregnancy event+ 1/3 labs + confirmed at least 12 weeks Hyperhomocysteinemia pathophsy not well understood, MTHFR gene DRVVT = dilute Russell’s viper venom time, venom is procoagulant by activating factor X (requires presence of prothrombin, factor V, and phospholipid) => mixing study Presents of lupus anticoagulant increases clotting time, will not correct with addition of normal plasma
Discussion on whether or not this patient had a provoked PE? American Academy of Chest Physicians
Case-fatality – at 3 months of anticoagulationRisk of anticoagulation depends on age (1.5 per 100 patient years in pts less than 60 to 4.5 in pts > 80)Bleeding meta-anlysis Annals in internal medicine 2003 pts on coumadin for VTERIETE Reigstry bleeding score (Cr > 1.2, anemia Hg < 13 men/12 women, cancer, clinically overt PE, age> 75)Determines risk of bleeding during first 3 months of anticoagulationNumbers appear to point to shorter anticoagulation but need to assess risk of recurrence and bleed risk
Follow up on patient= after ~ 1 year of coumadin, pt wants to stop, has family friend that suggested ASA, lovenox
causative/correlativePrevious LONFIT 1-2 4-6% develop DVT overall Lovenox not formally recommended by the AACPSeveral studies have shown reduced risk with stockings 4 => 0.2%, 10 => 0%
ICU vs. MSTHematologic vs. other ? Malignancy/iatrogenic Patient’s lifestyle may change (athletics/ increase in travel/ surgery/ etc)
