The document discusses pulmonary embolism (PE), which is a blockage of an artery in the lungs by a substance that has traveled from elsewhere in the body, such as a blood clot. Deep vein thrombosis (DVT) in the legs is the most common source of PE. Key signs and symptoms of PE include shortness of breath, chest pain, and tachycardia. Diagnostic tests include chest x-rays, CT scans, ventilation-perfusion scans, echocardiograms, and D-dimer tests. Treatment focuses on anticoagulation medications to prevent further clotting.

1. Pulmonary EmbolismPulmonary Embolism
Dr. Muhammad Bayazid
M.D Final part student, Cardiology, DMCH

2. DVT : Blood clot formation with inDVT : Blood clot formation with in
the large veins usually in the legsthe large veins usually in the legs
PE results from DVTs that havePE results from DVTs that have
broken off and travelled tobroken off and travelled to
pulmonary arterial circulationpulmonary arterial circulation
The majority of pulmonary emboliThe majority of pulmonary emboli
( 80%) arise from the propagation of( 80%) arise from the propagation of
lower limb DVTlower limb DVT
Other causes : Air, AmnioticOther causes : Air, Amniotic
Fluid, Fat EmbolismFluid, Fat Embolism
Venous thromboembolism
 DVT
 Pulmonary
Embolism

3. DEFINITIONDEFINITION
Pulmonary embolismPulmonary embolism ( (PEPE) is) is
a blockage of an artery in the lungs by aa blockage of an artery in the lungs by a
substance that has traveled from elsewhere in thesubstance that has traveled from elsewhere in the

4. Why it is important?Why it is important?
PE is the most common preventable cause ofPE is the most common preventable cause of
death in hospitalized patientsdeath in hospitalized patients
Majority of patient die because of failure ofMajority of patient die because of failure of
diagnosis rather than inadequate therapy.diagnosis rather than inadequate therapy.
80% of pulmonary emboli occur without prior80% of pulmonary emboli occur without prior
warning signs or symptomswarning signs or symptoms
Mortality rate without treatment is 30%,Mortality rate without treatment is 30%,
whereas with adequate treatment is only 2-8%whereas with adequate treatment is only 2-8%
Early treatment is highly effectiveEarly treatment is highly effective

5. TypesTypes

6. Non thrombtic pulmonaryNon thrombtic pulmonary
embolismembolism
 Fat embolism.Fat embolism.
 Air embolism.Air embolism.
 Amniotic fluid embolism.Amniotic fluid embolism.
 Tumor embolism (Tumor embolism (HCCHCC && RCCRCC).).

7. Thrombotic pulmonaryThrombotic pulmonary
embolismembolism

9. Hypercoagulability
Hereditary Deficiencies:
Antithrombin deficiency
Protein C deficiency
Protein S deficiency
Factor V Leiden
Prothrombin gene
mutation
Dysfibrinogenemia
Acquired:
Cancer
Pregnancy & postpartum
period
Oral contraceptives
Hormone replacement
therapy
Polycythemia rubravera
Smoking
Anti phospholipid syndrome
Chemotherapy
Stasis
Immobility/cast/travel
Advanced age
Acute medical illness
Major surgery
Spinal cord injury
Obesity
Endothelial Damage
Major surgery
Trauma
Central venous
catheterization
Risk for thromboembolism approximately doubles for each decade beyond
age 60 years
Risk factors

10. Major Risk (RR 5-20)Major Risk (RR 5-20)
•Major and abdominal surgeryMajor and abdominal surgery
•Lower Limb OrthopedicLower Limb Orthopedic SurgerySurgery
•Obstetric – Late preganancy,Obstetric – Late preganancy,
LSCS, Pre eclampsiaLSCS, Pre eclampsia
•Maliganancy- Pelvic ,Maliganancy- Pelvic ,
abdominal or metastaticabdominal or metastatic
•Lower Leg # , varicose veinsLower Leg # , varicose veins
•History of proven VTEHistory of proven VTE
Minor Risk Factors ( RR
CVS : HF, HTN, Congenital
Heart Disease, Central lines
Estrogen : OCP, HRT
Others : Occult malignancy,
COPD
Neurological disability, obesity,
thrombotic mayeloproliferative
disease, nephrotic syndrome
Inflammatory bowel disease
Risk factors

11. PathophysiologyPathophysiology

13. ClinicalClinical
PresentationPresentation Massive PEMassive PE::
Symptom:Symptom:
Severe central chest pain, Severe dyspnoea,Severe central chest pain, Severe dyspnoea,
Syncope, Pallor, Sweating,Syncope, Pallor, Sweating,
Sign:Sign:
Major circulatory collapse, tachycardia, hypotension,Major circulatory collapse, tachycardia, hypotension,
Shock,Shock,
Central cyanosis, Elevated JVP, Loud P2, S2 split,Central cyanosis, Elevated JVP, Loud P2, S2 split,
gallop rhythm.gallop rhythm.
 Small or Medium PESmall or Medium PE : SOB, Pleuritic chest pain,: SOB, Pleuritic chest pain,
Haemoptysis, Tachycardia, Tachypnea, Pleural rub.Haemoptysis, Tachycardia, Tachypnea, Pleural rub.
Crackles, pleural effusionCrackles, pleural effusion
 Chronic PEChronic PE: Exertional dyspnoea, symptoms of: Exertional dyspnoea, symptoms of
pulmonary HTN or right heart failure,pulmonary HTN or right heart failure,
17/08/1717/08/17 1313

14. Proportion with PE
65%
30
10%

17. 1717
DiagnosisDiagnosis
 CXRCXR
 ABG:ABG:
 ECGECG
 V/QV/Q
 Spiral CTSpiral CT
 EchoEcho
 AngioAngio
 Fibrin Split Products/D-dimerFibrin Split Products/D-dimer

18. Contd…Contd…
ECGECG
 Sinus tachycardia –Sinus tachycardia – m/c abnormality m/c abnormality
 Complete or incomplete RBBB –Complete or incomplete RBBB – a/w ↑ mortality a/w ↑ mortality
 RV strain pattern –RV strain pattern – T wave ↓ in the right precordial leads T wave ↓ in the right precordial leads
(V1-4) ± the inferior leads(V1-4) ± the inferior leads
 Right axis deviationRight axis deviation
 S1, Q3, T3 patternS1, Q3, T3 pattern
 Right atrial enlargement (P pulmonale) –Right atrial enlargement (P pulmonale) – peaked Ppeaked P
wave in lead II > 2.5 mm in heightwave in lead II > 2.5 mm in height
 Atrial Tachyarrhythmias –Atrial Tachyarrhythmias – AF, Flutter AF, Flutter
 Non specific ST-segment & T wave changesNon specific ST-segment & T wave changes

19. 1919
S1 Q3 T3 Pattern

20. 2020
T-wave inversion

21. 2121
Rt. Bundle Branch Block

22. 2222
Rt. Bundle Branch Block

23. Chest X-rayChest X-ray
 Chest X ray – most common finding with aChest X ray – most common finding with a
PE is a normal x-rayPE is a normal x-ray
 But they are useful as X-rays help to ruleBut they are useful as X-rays help to rule
out pneumonia and pneumothorax asout pneumonia and pneumothorax as
causes of dyspnoea etccauses of dyspnoea etc
 A normal CXR in the presence ofA normal CXR in the presence of
significant dyspnoea and hypoxemia insignificant dyspnoea and hypoxemia in
absence of bronchospasm and anatomicabsence of bronchospasm and anatomic
cardiac shunt is highly suggestive of PEcardiac shunt is highly suggestive of PE

24. Chest XrayChest Xray
 Chest radiograph findings in patient withChest radiograph findings in patient with
pulmonary embolismpulmonary embolism
ResultResult PercentPercent
CardiomegalyCardiomegaly 27%27%
Normal studyNormal study 24%24%
AtelectasisAtelectasis 23%23%
Elevated HemidiaphragmElevated Hemidiaphragm 20%20%
Pulmonary Artery EnlargementPulmonary Artery Enlargement 19%19%
Pleural EffusionPleural Effusion 18%18%
Parenchymal Pulmonary InfiltrateParenchymal Pulmonary Infiltrate 17%17%
Am Heart J
1997;134:479-87

25. Radiographic signs of acute pulmonaryRadiographic signs of acute pulmonary
embolismembolism
 Signs with relative high specificity but lowSigns with relative high specificity but low
sensitivity for acute pulmonary embolism:sensitivity for acute pulmonary embolism:
 Decreased vascularity in the peripheral lungDecreased vascularity in the peripheral lung (Westermark sign).(Westermark sign).
 Enlargement of the central pulmonary arteryEnlargement of the central pulmonary artery (Fleischner sign).(Fleischner sign).
 Enlarged right descending pulmonary arteryEnlarged right descending pulmonary artery (Palla's sign)(Palla's sign)
 Pleural based areas of increased opacity (Pleural based areas of increased opacity (Hampton humpHampton hump).).
 Hemidiaphragm elevation.Hemidiaphragm elevation.

26. (Hampton hump)(Hampton hump)
•The classic radiographic findings of
pulmonary infarction
• a wedge-shaped, pleura-based
triangular opacity with an apex
pointing toward the hilus

27. The Westermark sign : focal oligemia distal
to a PE

29. Atelectic band

30. D-dimerD-dimer
 By-product of fibrinBy-product of fibrin
degradationdegradation
 As clot degraded byAs clot degraded by
enzymes, Fibrinenzymes, Fibrin
Degradation ProductsDegradation Products
(FDP) are released, one(FDP) are released, one
of these is the D-dimerof these is the D-dimer
 Little clots in body releaseLittle clots in body release
D-dimers, therefore if testD-dimers, therefore if test
+ve - do not know if it is+ve - do not know if it is
from a PE,from a PE,
 But test is so sensitiveBut test is so sensitive
that if no D-dimer ( –ve)that if no D-dimer ( –ve)
you can rule out PEyou can rule out PE

31. CTPACTPA
 Contrast injected into body,Contrast injected into body,
 CT Scan obtained as this isCT Scan obtained as this is
occurringoccurring
 Vessels viewed on end andVessels viewed on end and
seen if they light up withseen if they light up with
contrast.contrast.
 If only partially light up withIf only partially light up with
contrast there may be a bloodcontrast there may be a blood
clot present stopping flowclot present stopping flow
 Do not use if in renal failureDo not use if in renal failure
((Creatanine) (could useCreatanine) (could use
HCOHCO33 cover to stopcover to stop
nephrotoxic effect of contrast)nephrotoxic effect of contrast)
 Unlike VQ Scan if patient hasUnlike VQ Scan if patient has
a pneumonia it will not affecta pneumonia it will not affect
resultsresults

32. CT findings of acute pulmonary embolismCT findings of acute pulmonary embolism
Vascular abnormalities:Vascular abnormalities:
 Intraluminal filling defects that forms an acute angle withIntraluminal filling defects that forms an acute angle with
the vessel wall & may be surrounded by contrast materialthe vessel wall & may be surrounded by contrast material
(polo mint sign or railway sign).(polo mint sign or railway sign).
 Total cutoff of vascular enhancement.Total cutoff of vascular enhancement.
 Enlargement of the occluded vessel.Enlargement of the occluded vessel.
Ancillary findings:Ancillary findings:
 Pleural based wedge shaped areas of increased attenuationPleural based wedge shaped areas of increased attenuation
with no contrast enhancement.with no contrast enhancement.
 Linear atelectasis.Linear atelectasis.

33. Partial eccentric filling defect with acutePartial eccentric filling defect with acute
angle with the vessel wallangle with the vessel wall

34. Intraluminal filling defectIntraluminal filling defect
(polo mint sign)(polo mint sign)

35. Intraluminal filling defectIntraluminal filling defect
(railway track sign)(railway track sign)

36.  V /Q lung scanning remains an option andV /Q lung scanning remains an option and
cancan be used when CTA is not available or isbe used when CTA is not available or is
contraindicated.contraindicated.
V /Q Scan
Advantages
relatively low radiation dose
no requirement for contrast
dye
Limitations
Unreliable in pts with COPD and
other conditions in which there is
structural Lung disease
When holding breath is difficult.

37. Normal
Ventilation
Left UL PE
Perfusion scanVentillation scan

38. Probability of PEProbability of PE
 Normal - Full ventilationNormal - Full ventilation
and perfusion seenand perfusion seen
 Low Pobability for PE –Low Pobability for PE –
(<20%)(<20%)
 Intermediate probabilityIntermediate probability
for PE-for PE- V andV and P inP in
same areasame area
(Matched deficit) (20-(Matched deficit) (20-
80%)80%)
 High Probability for PE –High Probability for PE –
Normal V andNormal V and P (Un-P (Un-
Matched deficit) (>80%)Matched deficit) (>80%)

39. Normal
Ventilation
Left UL PE
Perfusion scanVentillation scan

40. EchocardiographyEchocardiography
 This modality generally hasThis modality generally has
limited accuracy in thelimited accuracy in the
diagnosis.diagnosis.
 The overall sensitivity andThe overall sensitivity and
specificity for diagnosis ofspecificity for diagnosis of
central and peripheralcentral and peripheral
pulmonary embolism bypulmonary embolism by
ECHO is 59% and 77%.ECHO is 59% and 77%.
 It may allow diagnosis ofIt may allow diagnosis of
other conditions that may beother conditions that may be
confused with pulmonaryconfused with pulmonary
embolism.embolism.

41. ECHO signs of PEECHO signs of PE
 RV enlargementRV enlargement
 Hypokinesis especially free wall hypokinesis, withHypokinesis especially free wall hypokinesis, with
sparing of the apexsparing of the apex (the McConnell’s sign)(the McConnell’s sign)
 Interventricular septal flattening and paradoxicalInterventricular septal flattening and paradoxical
motion toward the LV resulting in a “D-shaped” LV inmotion toward the LV resulting in a “D-shaped” LV in
cross section.cross section.
 Tricuspid regurgitationTricuspid regurgitation
 Lack of inspiratory collapse of IVCLack of inspiratory collapse of IVC
 Direct visualization of thrombusDirect visualization of thrombus
 60/60 Sign-60/60 Sign- Acceleration time of RV ejection <60ms inAcceleration time of RV ejection <60ms in
the presence of TR pressure gradient </= 60mmHg.the presence of TR pressure gradient </= 60mmHg.

42. Echocardiograms before and after Thrombolysis
Echocardiography-RV Dilation

43. ECHOECHO
 The severity of this PulmonaryThe severity of this Pulmonary
Artery Pressure (PAP) and theArtery Pressure (PAP) and the
severity of the clot, is found byseverity of the clot, is found by
looking at the tricuspid valvelooking at the tricuspid valve
and noting how much regurgeand noting how much regurge
occurs (Tricuspid jet)occurs (Tricuspid jet)
 If tricuspid jet is high then PAPIf tricuspid jet is high then PAP
differential between RA anddifferential between RA and
RV is great and the clot burdenRV is great and the clot burden
is largeis large
 All these tests may help in theAll these tests may help in the
possible diagnosis of a PE, butpossible diagnosis of a PE, but
are not definitive testsare not definitive tests

45. UltrasoundUltrasound
 Non-invasiveNon-invasive
 Looks at lower limbsLooks at lower limbs
 Doppler USS looks atDoppler USS looks at
vein for flow andvein for flow and
compressibilty to seecompressibilty to see
if clot presentif clot present

46. Magnetic resonance angiographyMagnetic resonance angiography
(MRA)(MRA)
MRA appears promising & avoids ionising radiation but has poor
sensitivity for subsegmental clot.

47. MRA findingsMRA findings
 Visualization of the intravascular fillingVisualization of the intravascular filling
defect.defect.
 Provide physiologic information includingProvide physiologic information including
the regional distribution of ventilation &the regional distribution of ventilation &
perfusion.perfusion.

48. 4848
Pulmonary angiogramPulmonary angiogram

49. Pulmonary angiographicPulmonary angiographic
findingsfindings
Primary signs:Primary signs:
The only primary sign of acute pulmonaryThe only primary sign of acute pulmonary
embolism is filling defect.embolism is filling defect.
Secondary signs:Secondary signs:
Abrupt occlusion of pulmonary artery.Abrupt occlusion of pulmonary artery.
Areas of oligemia with pruning of theAreas of oligemia with pruning of the
branching vessels.branching vessels.

50. cardiac troponinscardiac troponins
•Recently, cardiac troponins I and T have been
shown to be associated with early mortality and
a complicated hospital course in patients with
PE.
The assessment of cardiac plasma troponin
levels revealed ventricular injury, especially in
patients with massive PE who had hypotension
or shock.

51. B Natriuretic PeptideB Natriuretic Peptide
(BNP)(BNP)
•BNP is a neurohormone secreted from the
cardiac ventricles in response to dilatation or
an increase of pressure.
• BNP levels may increase with right ventricle
dysfunction when the patients is in bed and
decrease with treatment.
•Serum brain natriuretic peptide levels of > 90 pg/mL
have a sensitivity of 85% and a specificity of 75% for
predicting adverse clinical outcomes

52. 5252
Autopsy findings of
PULMONARY EMBOLISM

54. Treatment optionsTreatment options
 Symptomatic treatment:Symptomatic treatment:
– ABCD approachABCD approach
– OxygenOxygen
– AnalgesiaAnalgesia
 Anticoagulation:Anticoagulation:
– IV HeparinIV Heparin
– S/C LMWH eg Enoxaparine, DalteparineS/C LMWH eg Enoxaparine, Dalteparine
– Oral WarfarinOral Warfarin
 IVC filter:IVC filter: If there is contra-indications for anti-coagulationIf there is contra-indications for anti-coagulation
 Thrombolysis:Thrombolysis: tPA eg Alteplase, TenectaplasetPA eg Alteplase, Tenectaplase
 Surgical procedures:Surgical procedures: Pulmonary embolectomyPulmonary embolectomy

55. General MeasureGeneral Measure
 Oxygen inhalationOxygen inhalation
 Opiates to relieve painOpiates to relieve pain
 Circulatory shock should be treated with I/V fluidCirculatory shock should be treated with I/V fluid
and plasma expenderand plasma expender
 Inotropic agents have limited value as hypoxicInotropic agents have limited value as hypoxic
dilated right ventricle maximally stimulated bydilated right ventricle maximally stimulated by
endogenous catecolaminesendogenous catecolamines
 Diuretics and vasodilator should be avoidedDiuretics and vasodilator should be avoided
because they reduce the cardiac output.because they reduce the cardiac output.
 Precordial thump , which may dislodge thePrecordial thump , which may dislodge the
thrombusthrombus

56. AnticoagulationAnticoagulation
 Ideally start Fast acting and slow acting anticoagulants,Ideally start Fast acting and slow acting anticoagulants,
when slow acting anticoagulants at desired level, stopwhen slow acting anticoagulants at desired level, stop
fast actingfast acting
 Fast acting -Heparin productsFast acting -Heparin products
Heparin (IV) orHeparin (IV) or
Low Molecular Weight Heparin (S/C)Low Molecular Weight Heparin (S/C)
 Slow acting – Vitamin K AntagonistsSlow acting – Vitamin K Antagonists
WarfarinWarfarin

57. HeparinHeparin
•The initial treatment of PE is LMWH or UHF for
at least 5 days, followed by warfarin.
•Dose of UFH: 80 U/kg bolus followed by18
U/kg/hour
. Monitoring by APTT(1.5-2.5 )times normal.
•It binds to endogenous antithrombin, This
heparin - antithrombin complex catalyzes the
inactivation of factor Xa and IIa (thrombin).

58. LMWHLMWH
.
•It should be used whenever possible for the
initial inpatient treatment of DVT & PE.
•Outpatient ttt of DVT, and possibly PE,is safe
and cost-effective for carefully selected
patients.

59. Adverse effect of heparinAdverse effect of heparin
•Adverse drug reactions include bleeding,
heparin-induced thrombocytopenia, and
osteoporosis .with prolonged use .

60. Oral anticoagulantOral anticoagulant
•We can give warfarin
•Target international normalised ratio
[INR], 2.0–3.0) for at least 3–6 months.

61. New oral anti coagulantNew oral anti coagulant
 Oral direct thrombin inhibitor: DabigatranOral direct thrombin inhibitor: Dabigatran
 It is as effective as warfarin for theIt is as effective as warfarin for the
treatment of acute VTE with similar safetytreatment of acute VTE with similar safety
profileprofile
 Dabigatran was also not inferior to S/CDabigatran was also not inferior to S/C
enoxaparin in the prevention of VTEenoxaparin in the prevention of VTE

62.  Oral direct factor X a inhibitor,Oral direct factor X a inhibitor,
RivaroxabanRivaroxaban
 It has relatively short half life 5-9 hoursIt has relatively short half life 5-9 hours
and rapid onset of action 2.5 to 4 hoursand rapid onset of action 2.5 to 4 hours
 It is not inferior to S/C enoxaparinIt is not inferior to S/C enoxaparin
followed by warfarin in the treatment offollowed by warfarin in the treatment of
acute symptomatic DVTacute symptomatic DVT

63. Duration of anticoagulationDuration of anticoagulation
•A patient with a first thromboembolic event occurring in the
setting of reversible risk factors, should receive warfarin therapy
for at least 3 months.
•Patients without a clearly defined predisposition to initial thrombo
embolism should be treated for 6 months or more.
•Patient who have active cancer or recurrent DVT require long
term ( indefinite period)

64.  Recurrent DVT & PE: Vena cava filterRecurrent DVT & PE: Vena cava filter
17/08/1717/08/17 6464

66. Indication of venacava filterIndication of venacava filter
 Contra indication to anti coagulationContra indication to anti coagulation
 Recurrent embolism while on adequateRecurrent embolism while on adequate
therapytherapy
 Significant bleeding complication duringSignificant bleeding complication during
anti coagulationanti coagulation

67. Thrombolytic TherapyThrombolytic Therapy
•The ACCP guidelines recommend that thrombolytic therapy
should be used in
•patients with acute PE associated with hypotension (systolic BP<
90 mm HG) who do not have a high bleeding risk .
•select patients with acute PE not associated with hypotension
and with a low bleeding risk whose initial clinical presentation or
clinical course after starting anticoagulation suggests a high risk of
developing hypotension
•Tissue plasminogen activator (tPA) has a short
infusion time and has been recommended as the best
agent for this reason.

69. EmbolectomyEmbolectomy
In case of massive life threateningIn case of massive life threatening
pulmonary embolismpulmonary embolism
 Catheter EmbolectomyCatheter Embolectomy
 Surgical EmbolectomySurgical Embolectomy
17/08/1717/08/17 6969

70. Catheter Embolectomy & FragmentationCatheter Embolectomy & Fragmentation
An alternative in high-risk PE patients when thrombolysis
is absolutely contraindicated or has failed
Kucher N Chest 2007;132:657-663

71. EmbolectomyEmbolectomy

72. PREVENTIONPREVENTION
Blood Pressure
Category
Systolic
mm Hg
Diastolic
mm Hg
Normal less than 120 and less than 80
Prehypertension 120 – 139 or 80 – 89
Stage 1 HTN 140 – 159 or 90 – 99
Stage 2 HTN 160 or higher or 100 or higher

73. Intermittent pneumatic compression (IPC) devices
are used to help prevent blood clots in the deep
veins of the legs. The devices use cuffs around
the legs that fill with air and squeeze your legs.
This increases blood flow through the veins of
your legs and helps prevent blood clots.

74. Intermittent pneumaticIntermittent pneumatic
compressioncompression

75. Graduated compressionGraduated compression
stockingsstockings
 Graduated compression stockings exertGraduated compression stockings exert
the greatest degree of compression at thethe greatest degree of compression at the
ankle, and the level of compressionankle, and the level of compression
gradually decreases up the garmentgradually decreases up the garment
 They are often used to treat chronicThey are often used to treat chronic
venous disease and edemavenous disease and edema

77. ComplicationsComplications
 Instant DeathInstant Death
 Chronic pulmonary hypertensionChronic pulmonary hypertension
 Respiratory failureRespiratory failure
 Congestive heart failureCongestive heart failure
 RecurrenceRecurrence
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78. Home messageHome message
 Prevention is better than curePrevention is better than cure
 Early diagnosis and treatment is lifeEarly diagnosis and treatment is life
savingsaving
 Risk of pulmonary embolism significantlyRisk of pulmonary embolism significantly
increases with a flight distance more thanincreases with a flight distance more than
5000 km or duration more than 8 hours .5000 km or duration more than 8 hours .