2. Pulmonary embolism (PE) - acute occlusion by
thrombus or embolus of a trunk or one or more
branches of the pulmonary arteries, which can
lead to acute and life-threatening but potentially
reversible right ventricular failure.
PE – the third type of pathology of the
cardiovascular system, which leads to death,
after ischemic heart disease and stroke.
3. Clinical (patient-related, usually transient)
• Stroke or paralysis of the lower extremities
• Severe myocardial contractile dysfunction (especially with CHF FC III-IV on the NYHA)
• Severe lung disease (especially with severe respiratory failure, mechanical ventilation)
• Sepsis
• Acute infection
• Active cancer (Brain, ovarian adenocarcinoma, pancreas, colon, stomach, lung, prostate, kidney), cancer
treatment (hormonal, chemotherapy, radiation)
•Inflammatory disease of the large intestine
• Arthritis of the joints of the lower extremities
• Age> 40 years (with an increase in the risk is growing; the usual grading> 40,> 60 and> 75 years)
• Bed rest, prolonged sitting position
• Previous episodes of venous thromboembolism
• Obesity
• Varicose veins of the lower extremities
• Nephrotic syndrome
• myeloproliferative disease
• Pregnancy and until 6 weeks after childbirth
• Using estrogens
• The catheter in the central vein
Risk factors for venous thrombosis and embolism (1)
Chest 2001; 119 (suppl.): 132S-175S, Chest 2004; 126 (suppl.): 338S-400S
4. Related to surgery, trauma
Major surgery
(Especially in the abdomen, pelvis, lower extremities)
Factors associated with the operation itself
• intervention area
• performance equipment
• duration
• type of anesthesia
• the presence of infection
• the extent and duration of the subsequent immobilization
Trauma
(Especially large, fracture bones of the pelvis, thigh or shin, spinal cord injury)
Risk factors for venous thrombosis and embolism (2)
Chest 2001; 119 (suppl.): 132S-175S, Chest 2004; 126 (suppl.): 338S-400S
6. pulmonary hypertension
1. When recurrent thromboembolism of small branches of the pulmonary
artery;
2. In history there is no heart and lung diseases, and the development of
chronic pulmonary heart - a consequence of the accumulation of previous
episodes of pulmonary embolism
Clinic picture:
1) Episodes of suddenly arisen and / or shortness of breath quickly
passing
2) Swelling of neck veins
3) Hepatomegaly
4) Ascites
5) Swelling of the feet
7. When the central pulmonary embolism (The massive):
-respiratory rate> 20 per minute;
-quickly emerging, isolated dyspnoea;
-fainting, shock, hypotension;
-chest pain similar to angina may reflect ischemia of RV
When PE medium and small branches (Submassive, nonmassive):
-increasing shortness of breath for a few weeks;
-the absence of other causes of increasing shortness of breath;
-increased shortness of breath might be the only sign of pulmonary embolism
in patients with heart or respiratory failure
Clinic of PE
8. ECG
Chest X-ray
echocardiography
Laboratory research
Lung perfusion scintigraphy
Angiography - diagnostic standard, but only in cases where
the results of non-invasive methods are controversial
Radiopaque CT, CT angiography, CT venography
MRI
Accurate diagnosis of the of pulmonary embolism
9. Markers of thrombinemia
1) Products conversion of fibrinogen to fibrin - soluble fibrin monomer
complex (SFMC);
2) Small fragments of fibrin resulting from the spontaneous lysis of a
blood clot - D-dimers (> 500 ng / ml indicates the presence of deep
vein thrombosis or pulmonary embolism);
3) Products conversion of prothrombin to thrombin (are watching in the
most advanced centers):
- thrombin-antithrombin III (TAT)
- prothrombin fragments 1 + 2 (FP1 + 2)
10. The dependence of D-dimer specificity of patient
characteristics
The specificity of the method depends on the patient and reduced:
- With age, in patients> 80 years of specificity may be <10%;
- Specificity decreases in cancer patients;
- The specificity decreases in pregnancy
11. There may be increased levels of troponin T and I, associated with
myocardial infarction and damage to the right ventricle (despite the
absence of changes in the coronary arteries)
(+) Troponin T in 1/3 patients with submassive and 1/2 patients with
massive pulmonary embolism
(+) Troponin T - increasing the risk of in-hospital mortality in 15 times in
comparison with the troponin T (-) patients (44% mortality in patients
with (+) and troponin T with 3% (-) troponin T)
(+) troponins T and I are correlated with a complicated clinical course
of pulmonary embolism
The correlation of PE with the level,
troponin T and I
12. RV dysfunction is accompanied by a stretching of the
myocardium, with is released of brain natriuretic peptide
(BNP)
In acute PE levels of BNP and N-terminal proBNP (NT-
proBNP) reflect the severity of the violation of RV function
and hemodynamics
Complement the prognostic information obtained by
echocardiogram
BNP - laboratory markers of RV
dysfunction
13. Clinical classification of pulmonary embolism
European Society of Cardiology 2008
High risk of death>
15%
Intermediate risk 3-
15%
Low risk <1%
• shok
• hypotension
•(SBP <90 or a decrease of DBP < 40 mmHg
•at least 15 minutes,
•not associated with an arrhythmia,
•hypovolemia or sepsis)
and/or
RV dysfunction and markers of myocardial
damage
No shock or hypotension, RV dysfunction
and markers of myocardial damage
Massive
Submassive
Nonmassive
14. Index PESI Simplified index
PESI
Age 1 per year If 1> 80 years
Sex 10
The history of cancer 30 1
The history of HF 10
The history of chronic disease of lung 10
Heart rate ≥110 20 1
Systolic BP <100 30 1
RR respiratory rate ≥30 20
Т <36С 20
Altered mental state 60
SaO2 arterial blood <90% 20 1
• Class I (0-1,6%)
• Class II (1,7-3,5%)
• Class III (3,2-7,1%)
• Class IV (4,0-11,4%)
• Class V (10,0-24,5%)
≤65
66-85
86-105
106-125
>125
0 points = risk of
death of 1.0%
1 points = risk of
death of 10,9%
PE: assessing the risk of death within the next 30 days
1
15. The probability of early death from pulmonary embolism
The risk of death
from pulmonary
embolism
The shock
or
hypotension
Class III-IV for
PESI index or
score ≥1 a
simplified index
PESI
Signs of right
ventricular
dysfunction
with
visualization
(ECHO or CT)
Elevated
cardiac
biomarkers
Guidelines of the European Society of Cardiology (2014)
(1) Damage of
the myocardium :
Troponin
or
(2) Disfunction of RV:
BNP, NT-proBNP
At the hospital
or up to 30 days
(1) ECHO: the myocardium
RV dilatation;
ratio RV / LV in diastole> 0.9 or 1.0;
hypokinesis of RV free wall;
heightened speed of the jet of
tricuspid regurgitation;
a reduction in systolic displacement
of
tricuspid valve ring plane
or a combination thereof
or
(2) CT angiography:
ratio RV / LV in diastole> 0.9 or 1.0
SBP <90 or
reduction of ≥40
more than 15 min,
not caused by
appeared
arrhythmia,
hypovolemia
or sepsis
16. Clinical suspicion of pulmonary embolism
Shock / hypotension?
See. Diagnostic algorithm
Evaluation of index PESI
Intermediate risk
PE: treatment strategy (Europe 2014)
Reperfusion
treatment +
anticoagulants
yes
See. Diagnostic algorithm
no
PE is confirmed
Class III-IV or ≥1 points
Class I-II
or 0 points
Low risk
PE is confirmed
High risk
Anticoagulants;
to discuss the early
an extract and treatment at home
Intermediate –high
risk
Intermediate -low
risk
Anticoagulants;
hospitalization
Anticoagulants
when aggravation
of symptoms to discuss reperfusion
Dysfunction of the RV + biomarkers
Both positive
One positive
or both negative
17. Approaches to the treatment of pulmonary embolism
Massive
High risk
thrombolysis,
embolectomy or
venous filter
+
Anticoagulants
Submassive
Intermediate risk
Anticoagulants;
expediency of
thrombolysis,
embolectomy or
venous filter
not clear
Small
Low risk
Anticoagulants;
Heart disease, 8th edition, 2008
18. The approaches to the use of anticoagulants in PE
Parenteral injections
Unfractionated heparin, low molecular weight
heparin or fondaparnuks
(Therapeutic dose)
≥5 days =
adjustment of the dosage to the
vitamin K antagonists
≥3 months
Vitamin K antagonists,
target INR 2-3
Subcutaneous administration of LMWH
(Therapeutic dose)
1 month ≥3-6 months
Subcutaneous administration of LMWH
(Therapeutic dose or 75-80% of therapeutic dose)
Parenteral injections
Unfractionated heparin, low molecular weight
heparin or fondaparnuks
(Therapeutic dose)
≥5 days
≥3 month
≥3 month
Apixaban, rivaroxaban
Dabigatran etexilat
± Parenteral injections
UFH, LMWH or fondaparnuks
(Therapeutic dose)
19. Indications for cava - filter installation:
thrombosis of deep veins of lower extremities with
having no occlusive (of floating) thrombus: set a
permanent cava filter;
venous thrombosis of the lower extremities with the
presence of episodes of pulmonary embolism: set a
permanent cava filter;
venous thrombosis of the lower extremity in
pregnancy and childbirth: set temporary or
permanent cava filter;
conducting operations on the veins, laparoscopic
interventions for pelvic vein thrombosis: at the time
of surgery and immediate postoperative period is set
to a temporary vena cava filter.
