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ASSESMENT OF PULMONARY THROMBOEMBOLISM
PATIENTS DIAGNOSED IN OUR CLINIC
A. Şimşek, G.Ö. Türkkan, K. Melek
F.Ö.Eyüboğlu
University of Baskent, Department of Chest Disease
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INTRODUCTION
• Venous thromboemboli (VTE) is the third most common cardiovascular disease after the ischemic heart disease and stroke.
• The risk of PTE increases with advanced age
• It was seen in male and female with same ratio
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PULMONARY THROMBOEMBOLISM (PTE)
• Annual incidence : 0.23-1.83/1000
• Mortality rate :– without treatment: 30 %– with treatment: 14.7
• Cause can not be identified at 19-47%
• Recurrance:– First year: 7-8 %
– After 8-10 years: 30 %
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RISK FACTORS FOR PTE
• Immobilization• Malignancy
• Trauma• Advanced age• Cardiopulmonary dis.
• Surgery• Previous VTE• Obesity• Cerebrovasculary disease• OC usage
ACQUIRED RISK FACTORS
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RISK FACTORS
• Antiphospholipid Antibody Synd
• Prothrombin 20210 A mut.
• Increased Lipoprotein A • Methylentetrahydrofolate
reductase mutation(?)
GENETIC RISK FACTORS
• Antithrombin III deff
• Protein C defficiency
• Protein S defficiency
• FV Leiden mutation
• Hyperhomocysteinemie
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AIM
The aim of this study was to define risk factors for PTE, clinical characteristics, demographic data of subjects, diagnostic procedures, and treatment responses
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MATERIAL AND METHOD
We retrospectively analysed data from 164 patients admitted to our clinic with PTE in our hospital between 2000 to 2005
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MATERIAL AND METHOD • Sex• Age• Risk factors• Symptoms• Thorax CT• Lower extremities
venous doppler US
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MATERIAL AND METHOD
• Severity of PTE
• Drugs used for treatment
• Mortality rate
• Recurrance rate
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RESULTS
• Female ratio : 55.5 %• Male ratio : 44.5 %
• Mean Age : - Female : 69.3 ± 13.6 - Male : 62.7 ± 18.3 - General : 66.3 ± 16.1
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RESULTS
• Risk factors for PTE were absent in 25.6% of patients (idiopathic)
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29,9%
15,2%
1,2%0,6%
12,5%
6,1%9,2%
28%
16,5% Immobilization
Surgery
Heart Failure
Malignancy
Trauma
Previous VTE
OralContraceptiveVasculitis
Cerebrovasculary disease
RISK FACTORS FOR PTE
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2,1%
4,5% 4,5%6,5%
6,5%
8,7%
10,8%13%
39%
Lower extremitysurgeryThorax-lumbalsurgeryGynecologicalsurgeryCoronary arterialbypass graftAbdominoplasty
Urological surgery
Cranial
Aorta surgery
Cataract surgery
Rectum Surgery
Mastectomy
Tympanectomy
SURGERY TYPE
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13,6%
18,1%
4,5% 9%9%
13,6%
13,6%13,6%
Prostate
Liver
Breast
Heamatologic
GIS
Lung
Gynecologic
Surrenal
MALIGNANCY
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76.2
50
26.823.8
15.914.6 148.5 6.1
01020304050607080 Dyspnea
Chest pain
Edema,rednessat extremitiesCough
Fever
Weakness
Sputum
hemoptysis
syncope
SYMPTOMS
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38,4
16,5
11,6
84,8
63,6
4,2
33,1
11,9
0 20 40 60 80 100
Tachycardia
Hypotention
Tacypnea
Hypoxia
Hypocapnia
Hypercapnia
Res.alcalosis
Acidosis
Arterial blood gasesPhysical examination
SIGNS
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Bilateral embolism 70.7 %
Unilateral embolism
- Right
- Left
29.3 %
61.4 %
38.6 %
LOCALIZATION OF PTE
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Minör embolism 62.3 %
Submassive embolism 21 %
Massive embolism 16.7 %
SEVERITY OF PTE
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THROMBUS (+) 45.6 %
THROMBUS (-) 54.4 %
BILATERAL 23.5 %
UNILATERAL -RIGHT -LEFT
76.5 % - 59.6 % - 40.3 %
PRESENCE OF LOWER EXTREMİTES VENOUS THROMBUS
The ratio of cardiac thrombus was 5.5 %
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Heparin 68.3 %
Low moleculer weight heparin
43.3 %
Warfarin 84.8 %
Thrombolytic drugs 9.8 %
DRUGS USED FOR TREATMENT
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Mortality 11 %
Recurrance 14.8 %
FOLLOW UP
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DISCUSSION
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• Most frequently seen risk factors– Immobilization– Surgery
• Most frequently seen surgery
Sugery to lower extremities
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Idiopathic Immobilisation Surgery Malignancy Heart Failure
Trauma Previous VTE
ICOPER(1999)
19 % 28.1 % 28.9 % 22.5 % 10.5 % 11.2 % 24.9 %
Heit et al.(2000)
26 % 59 % 24 % 18 % 10 % 12 % 5 %
Cushman et al(2001)
47 % 25 % 25 %
Richard at al(2003)
41 % 23 % 18 % 2 %
Present Study( 2007)
25.6 % 29.9 % 28 % 12.8 % 16.5 % 9.2 % 6.1 %
RISK FACTORS FOR PULMONARY EMBOLISM
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Prostate CA
Liver CA Breast CA Lung CA Colon CA Pancreas CA
Rickler ve ark.(1983)
6.5 % 2 % 25.6 % 15.2 % 17.4 %
Levitan et al(1999)
17 % 21 % 18 %
Kolomansky et al(2006)
14 % 16 % 11 % 10 %
Present Study(2007)
18.1 % 13.6 % 13.6 % 9 % 4.5 %
MALIGNANCY RATES IN PULMONARY THROMBOEMBOLISM
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In this study;
• Lung and rectum cancer rates were lower than other studies
• Liver cancer rate was higher than other studies
• Pancreas cancer was not seen anymore
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• According to our study, all malignancies can cause PTE
• Our hospital is a solid organ transplantation center, for that reason liver cancer rate might be found high
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• Lower ext. thrombus rate
• Cardiac thrombus rateSimilar with literature
Recurrance rate was higher than literature
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Recurrance Rate(%)
Prandoni et al (1996) 8.6 %
ICOPER (1999) 7.9 %
Hansson et al (2000) 7 %
Heit et al (2000) 12.9 %
Cushman et al (2001) 7.7 %
Our study (2007) 14.8 %
RECURRANCE RATE IN PULMONARY EMBOLISM
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• The reason of high recurrance rate of PTE in our study may be associated with long term (5 year) follow up
• Long term follow up is more informative than 6-12 months follow up in determining recurrance rate
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• Mortality rate was lower than literature
• Early diagnosis• Early treatment• Long term follow up
Effective in determining low mortality rates
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Mortality Rate (%)
Anderson et al (1991) 25 %
ICOPER (1999) 17.4 %
Cushman et al (2001) 15.1 %
Murin et al (2002) 14.7 %
Our study (2007) 11 %
MORTALITY RATES IN PULMONARY EMBOLISM
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RESULTS In order to determine correct recurrance
rates, 5 year follow up is necessary Long term and near follow up may reduce
mortality In presence of malignancy, VTE should be
kept in mind as a complication Because of high rate of idiopathic PTE,
hereditary thrombophylic factors should be searched in all patients