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Updated Management of:
ABDULRAHMAN AL-RAFIQ
TEACHING ASSISTANT – DEPARTMENT OF CARDIOLOGY - SANA’A UNIVERSITY
CARDIOLOGY M.D. CANDIDATE
ACUTE PULMONARY
EMBOLISM
VTE
DVT
PE
A. PE
Agenda
▪ Introduction
▪ Etiology
▪ Clinical Features
▪ Diagnosis
▪ Treatment
▪ Prognosis
INTRODUCTION
Susruta
Giovanni
INTRODUCTION
Rudolf Virchow
Susruta (Ayurveda physician
and surgeon, 600-1000 B.C) –
patient with a “ swollen and
painful leg that was difficult to
treat”
Giovanni Battisa Morgagni,
1761 – recognized clots in
pulmonary arteries after sudden
death, but didn’t make the
connection to DVT
Coined the terms
“THROMBOSIS”
And
“EMBOLISM”
RUDOLF VIRCHOW
Discovered PE in 1846
“ The detachment of larger or
smaller fragments from the end of a
softening thrombus which are
carried along the current of blood
and driven into remote vessels. This
gives rise to the very frequent
process on which I have bestowed
the name Embolia”
RUDOLF VIRCHOW
Introduction
❑ Thrombi often develop within the leg or pelvic veins, and approximately
halfof all DVT embolize to the lungs.
❑ The annual incidence 1 in 1000persons
❑ Almost 20% of patients who are treated for pulmonary embolism
dies within 90 days
ON AVARAGE,ONE AMERICAN
DIES OF BLOOD CLOT
EVREY 6 MINUTES.
PE Anatomical Types
EMBOLISM OF LESSER
DEGREE WITHOUT
INFARCTION
PULMONARY
INFARCTION MASSIVE
EMBOLIZATION
PE Anatomical Types
MASSIVE
EMBOLIZATION
Complete surgical specimen of
large pulmonary clot-in-transit
Massive PE (5%)
Submassive PE (25%)
PE with Normal BP & RV Function (70%)
5%
25%
70%
PE Functional Types
•Normal BP, Normal RV Function
•Good Prognosis with anticoagulation therapy
PE with Normal BP & RV Function (70%)
N N
PE Functional Types
•Normal BP, RV Dysfunction
•Higher risk of complications
Submassive PE (25%)
N
PE Functional Types
•Hypotension (SBP<90), Cardiogenic shock, Arrest
•Respiratory failure
Massive PE (5%)
PE Functional Types
• Hypotension (SBP<90), Cardiogenic shock, Arrest
• Respiratory failure
Massive PE (5%)
• Normal BP, RV Dysfunction
• Higher risk of complications
Submassive PE (25%)
• Normal BP, Normal RV Function
• Good Prognosis with anticoagulation therapy
PE with Normal BP & RV Function (70%)
PE Functional Types
RV Dysfunction
RV Dysfunction
ETIOLOGY
Risk Factors
❑ Hypercoagulability
❑ Malignancy
❑ Immobilization
❑ Trauma
❑ Post- operative
❑ Burns
❑ Infections (COVID-19)
❑ Excess estrogen
Post-
operative
or post-
partum
Phlegmasia alba
dolens (milk leg)
Extensive pelvic or
abdominal operations
Hip operations
Coagulation
disorders Trauma
Malignancy
Oral contraceptives Fractures: also
soft tissue injury
Local
disorders;
varicositie
s,phlebitis
Prolonged
bed rest
Prolonged
sitting
Heart
failure
Venous
stasis
Most common
sources of
pulmonary
emboli
EIV
FV
DFV
PV
PTV
SPV
Less common
sources of
pulmonary
emboli
Rt side of
heart
Gonadal
veins
Uterine
vein
Pelvic
V.P.
GSV
SSV
Most common
sources of
pulmonary emboli
EIV
FV
DFV
PV
PTV
SPV
Less common
sources of
pulmonary emboli
Rt side of heart
Gonadal veins
Uterine vein
Pelvic V.P.
GSV
SSV
Factors that increase a woman’s
risk for VTE during pregnancy,
childbirth, and after delivery
in
CLINICAL FEATURES
Common symptoms of pulmonary embolism
Fatigue
Chest pain
Cough
Fever
Breathlessness
Dizziness
Diaphoresis
Hemoptysis.
 A history of dyspnea, immobilization, recent surgery,
active cancer, hemoptysis, previous venous
thromboembolism, or syncope was associated with an
increased likelihood of pulmonary embolism.
 Testing for pulmonary embolism should also be considered if a patient
appears not to have had a response to treatment for another
diagnosed respiratory condition, because initial misdiagnosis
is common.
DVT
PE
CHEST PAIN
DIAGNOSIS
Pulmonary Embolism Rule-out Criteria
(PERC)
D- dimer less useful in ruling out pulmonary
embolism because levels are often elevated during
illness and after surgery.
(PERC) Can safely rule out pulmonary embolism
without further diagnostic imaging
 To minimize lung and breast-
tissue irradiation in younger
patients
 Ventilation–perfusion single-
photon-emission CT (SPECT)
is a low-radiation option.
TREATMENT
Initial treatment is guided by classification of
the pulmonary embolism as
Low-risk
Intermediate-risk
High-risk
Low-risk PE
Most patients have low-risk pulmonary
embolism, and their care can be managed
at home with a direct oral
anticoagulant
LMWH
LMWH
DOAC
Provoked
Persistent risk factor
Risk of Bleeding vs
Recurrent VTE
Patient Preferences
3 Months
6 Months
Indefinite
Unprovoked PE
Provoked PE
Unprovoked PE
Intermediate risk PE
Intermediate risk PE
UFH Bleeding
Not studied
DOAC
LMWH
High-risk PE
High-risk PE
 Immediate reperfusion therapy by ruling out
contraindications (e.g., brain metastases,
bleeding disorders, and recent surgery)
High-risk PE
Catheter-directed
thrombolysis
Systemic
thrombolysis
Surgical
thrombectomy
PROGNOSIS
❑pulmonary embolism is not commonly
the cause of death
❑Frequently complicates other
serious conditions.
❑The true mortality is estimated to
be less than 5%
ABDULRAHMAN AL RAFIQ UPDATED MANAGEMENT OF ACUTE PULMONARY EMBOLISM .pdf

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ABDULRAHMAN AL RAFIQ UPDATED MANAGEMENT OF ACUTE PULMONARY EMBOLISM .pdf