Pulmonary embolism

1. PULMONARY EMBOLISM
DR.SAKIL AHAMMED
2nd year resident DNB General Medicine

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

4. PATHOPHYSIOLOGY :
 ACTIVATED PLATELETS
 INFLAMMATION
 PROTHROMBOTIC STATES
 CLINICAL RISK FACTORS

5. ACTIVATED PLATELETS
DESCRIBED BY RUDOLF VIRCHOW IN 1856

6. INFLAMMATION- CAN TRIGGER PE/DVT:
AUTO-INFLAMMATORY
 ULCERATIVE COLITIS
 CROHN’S DISEASE
 RHEUMATOID ARTHRITIS
 PSORIASIS
 DIABETES MELLITUS
 OBESITY/METABOLIC SYNDROME
 DYSLIPIDEMIA

7. INFLAMMATION- CAN TRIGGER PE/DVT:
INFECTIVE/TRIGGERS
 PNEUMONIA
 ACUTE CORONARY SYNDROME
 ACUTE STROKE
 SMOKING
 SEPSIS/SEPTIC SHOCK
 ERYTHROPOIESIS-STIMULATING AGENT
 BLOOD TRANSFUSION
 CANCER.

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

9. PROTHROMBOTIC STATES:
 SYSTEMIC MALIGNANCY
 POLYCYTHEMIA VERA . SLE , HOMOCYSTINYRIA
 THROMBOTIC THROMBOCYTOPENIC PURPURA
 NEPHROTIC SYNDROME AND IBD

10. CLINCAL RISK FACTORS
MODIFIABLE RISK FACTORS :
 OBESITY
 METABOLIC SYNDROME
 SMOKING
 HYPERTENSION
 DYSLIPIDEMIA
 HIGH CONSUMPTION OF RED MEAT AND LOW CONSUMPTION OF FISH,FRUITS
AND VEGETABLES
 OCP
 HRT

11. NON-MODIFIABLE RISK FACTORS
 ADVANCING AGE
 PREVIOUS H/O-PE OR FAMILY H/O-PE
 ARTERIAL DISEASE - CAROTID AND CORONARY.
 RECENT SURGERY,TRAUMA OR IMMOBILTY,INCLUDING STROKE.
 CONGESTIVE HEART FAILURE
 COPD
 ACUTE INFECTION
 AIR POLUTION
 LONG AIR TRAVEL

12. NON-MODIFIABLE RISK FACTORS :
 PREGNANCY
 PACEMAKER
 ICD OR INDWELLING CENTRAL VENOUS CATHETER.

13. CARDIOPULMONARY DYNAMIC:

14. CLASSIFICATIONS :
 HEMODYNAMIC CLASSIFICATION
- MASSIVE PE >50 % OCCLUDED
- SUB-MASSIVE PE 30-50% OCCL.
- SMALL PE < 30 OCCL

15. CLASSIFICATION:
 PATHOPHYSIOLOGIC CLASSIFICATION
THROMBUS – DVT OF LOWER LIMB VEINS
NON- THROMBUS – AMNIOTIC FLUID, FAT EMBOLISM, AIR EMBOLISM, SEPTIC
EMBOLUS, TUMOR (RA MYXOMA)

16. CLASSIFICATION :
 PROVOKED – ASSOCIATED WITH RISK FACTORS
 UNPROVOKED – WITHOUT A CLEAR RISK FACTORS

17. CLINICAL FEATURES:
 SYMPTOMS-
 UNEXPLAINED DYSPNEA
 CHEST PAIN, EITHER PLEURITIC OR ATYPICAL.
 ANXIETY
 COUGH

18. SIGNS :
 TACHYPNEA
 TACHYCARDIA
 HYPOXIA
 LOW-GRADE FEVER
 LEFT PARASTERNAL LIFT
 TRICUSPID REGURGITANT MURMUR
 ACCENTUATED P2,CREPTS.
 HEMOPTYSIS
 LEG,ERYTHEMA, TENDERNESS

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.

20. S1Q3T3:

21. CHEST X-RAY:
POOR SENSITIVITY
1. HAMPTON HUMP- WEDDGE SHAPED OPACITY IN THE PERIPHERY.

22. WESTERMARK’S SIGN :
 OLIGEMIA OF LUNG FIELD

23. PALLA’S SIGN :
 ENLARGED RIGHT DESCENDING ARTERY

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.

27. ECHOCARDIOGRAPHY :
RA RV DILATATION
RV FUNCTION /HYPOKINESIA
RA RV CLOTS
PA PRSSURE

29.  CT-CHEST
 CT PULMONAR ANGIOGRAM (GOLD STANDARD)

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

32. DIFFERENTIAL DIAGNOSIS OF
PULMONARY EMBOLISM:
 ANIXETY,PLEURISY,COSTOCHONDRITIS
 PNEUMONIA,BRONCHITIS
 MYOCARDIAL INFARCTION
 PERICARDITIS
 CONGESTIVE HEART FAILURE
 IDIOPATHIC PULMONARY HYPERTENSION

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

43. ORAL ANTICOAGULANT :
*NOAC PREFERRED OVER VKA(VITAMIN-K ANTAGONIST )
VKA
 WARFARIN
 ACENOCOMAROL
 TARGET INR 2.0-3.0
ANTIDOTE- VIT-K
*REF-HARRISION 21ST EDITION PAGE NO-2098

44. NOAC(NOVEL/NEWER/NON-VIT-K OAC):
DABIGATRAN 150 MG BID
ANTIDOTE – IDARUCIZUMAB
APIXABAN 10MG BID
RIVAROXABAN 15 MG BID
EDOXABAN 60MG OD
ANTIDOTE- ANDEXANET ALFA.

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.

46. SURGICAL :
 PULMONARY EMBOLECTOMY
 IVC FILTERS (TO PREVENT RECURRENT EMBOLI)

47. IVC FILTER:

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)

50. THANK YOU