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PULMONARY
EMBOLISM
ISWANTO PRATANU
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Introduction
DVT
VTE
PE
o Acute PE is the mostserious clinical
presentation of VTE
o incidence of 100–200 per
100 000 inhabitants
omortality rate 15% in thefirst 3 months after
diagnosis
oThe epidemiology of PE
is difficult to determine
asymptomatic
(Goldhaber 2003 Merrigan 2013)
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Risk Factor
o Immobilization
o Travel of 4 hours or more in the past month
o Surgery within the last 3 months
o Malignancy (17%)
o History thromboplebitis
o Trauma to lower extremities and pelvis during past 3 mos
o Smokingo Central venous instrumentation within past 3 months
o Stroke
o Prior pulmonary embolism
o Heart failure
o COPD
o Hypercoagulable states (hereditary)
o Hormonal therapy
(Stein 2007) (Ouelette DR 2015)
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Pathophysiology
Circulation
Gas exchange
Neurohormonals
Pulmonary vascular
obstruction
RV dilatations
Vasoconstriction
↑ pulmonary resistance ↓ compliance artery
Chemical factorsEmbolus
RV heart failure↓ CODesaturation
Disturbance
ventilation-
perfusionHypoxemia
PE
(Goldhaber 2003,
Konstantinides 2014)
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2014 ESC Guidel ines on the diagnosis and m anagement of acute
pu lmonary embol ism
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Diagnosis
Clinical manifestation of PE is not specific
Suspected PE:
•Dyspneu•Chest pain
•Presyncope or syncope
•Haemoptysis (coughing up blood)
•Palpitations
•Leg swelling and discomfort
(Goldhaber 2003)
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Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED)
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(Konstantinides 2014)
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Scoring system
(Wells 2000)
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Scoring system
(La Gal 2006)
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Laboratory Test
D-Dimer
• Suspected low or
intermediate risk of
PE
• ELISA method:
sensitivity 95%
• Specificity decreased
almost 10% in >80
years old
(Vyas 2012, Konstantinides 2014)
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Laboratory Test
BNP
• Increase in about 50% PE patients
• Higher sensitivity as indicator in heart failure
Troponin I or T
• Increase in PE patients
(Binder 2005, Lankeit 2013, Konstantinides 2012)
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Imaging Test
Joseph, Nicholas JR. CE Essentials
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Imaging Test
Echocardiography• Detect morphology dan function changes of RV
• Prognostic value in unstable haemodynamics
patients is still the best
• No sign of RV overload or dysfunction exclude
suspected high risk PE
(Konstantinides 2014)
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Thrombus
Thrombus
Thrombus
Thrombus
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Imaging Test
CT Angiography• Standart imaging for
patient with
suspected PE
• Adequate imaging
pulmonary vascular to segmental level
• MDCT giving
imaging of thrombus
in pulmonary
vascular, detect RVdilatation and RV
dysfunction
(Lucassen 2013, Konstantinides 2014)
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(Konstantinides 2014)
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(Konstantinides 2014)
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Therapy
Haemodynamic and Respiratory Support
• Supportive treatment is vital acute RV failure
low systemic output cause of death
• Modest (500 ml) fluid challenge
help increasecardiac index
• Vasopresor is often necessary
• NE improves RV function via direct positive inotropic
effect
• Dobutamine or dopamine considered for patient withlow cardiac index and normal BP
(Konstantinides 2014)
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Therapy
Anticoagulation
• Recommended to
prevent early death and
recurrent symptomatic
or fatal VTE• Standard duration at
least 3 months
• Acute phase treatment
consist of parenteral
UFH, LMWH or fondaparinux over first
5-10 days(Quinlan 2004, Buller2012)
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Therapy -- Thrombolysis
(Konstatinides 2012, Lavorini 2013)
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Therapy
Systemic thrombolysis is not routinelyrecommended as primary treatment for patients
with intermediate-high risk PE, but should be
considered if clinical signs of haemodynamic
decompensation appear
Percutaneous catheter-directed treatment or
surgical pulmonary embolectomy are
alternative rescue procedures for intermediate-
high risk PE
(Konstatinides 2012, Lavorini 2013)
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Prognostic
(Jimenez 2010, Konstatinides 2014)
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Summary
• PE has high morbidity and mortality• The diagnose of PE is difficult to determine
because remain asymptomatic
• Risk stratification need to be done for suspected PE to determine diagnosis and
therapy
• With prompt diagnosis and management,
recurrent PE and mortality could be prevented
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THANK YOU