dvt&pe final 1
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PULMONARYEMBOLISM
Dr. Mehreen SaiyedResident
Med 4
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-Introduction
-Clinical features
-Diagnostic modalities-Diagnostic approach
-Management
Objectives
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In pulmonary embolism, a thrombus arises elsewhere in the
body and migrates to the pulmonary vascular tree, where it
causes obstruction.
Nearly all pulmonary emboli derive from
deep venous thrombosis.
Introduction
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http://www.ceessentials.net/article12.html
Introduction
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SYMPTOMS IN PATIENTS WITH ANGIO PROVEN PTE
Symptom Percent
Dyspnea 84
Chest Pain, pleuritic 74
Anxiety 59
Cough 53Hemoptysis 30
Sweating 27
Chest Pain, nonpleuritic 14
Syncope 13
Clinical features
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SIGNS WITH ANGIOGRAPHICALLY PROVEN PE
Sign Percent
Tachypnea > 20/min 92Rales 58Accentuated S2 53Tachycardia >100/min 44
Fever > 37.8 43Diaphoresis 36S3 or S4 gallop 34Thrombophebitis 32
Lower extremity edema 24
Clinical features
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Diagnostic difficulties!
Signs / symptoms non-specific
Only 25% of suspected casesactually have pulmonary emboli1,2
1. Lee AY, Hirsh J. Diagnosis and treatment of venous thromboembolism. Annu Rev Med. 2002;53:15-33.2. The PIOPED Investigators. Value of the ventilation/perfusion scan in acute
pulmonary embolism: results of the Prospective Investigation of PulmonaryEmbolism Diagnosis (PIOPED).JAMA. 1990;263:2753-2759.
Clinical features
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- PRETEST PROBABILITY
Definition: The probability of the targetdisorder (PE) before a diagnostic test result is
known.
Used to decide how to proceed withdiagnostic testing and final disposition
Who do we work up?
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Modified Wells pretest probability scoring
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Diagnostic Modalities
ABG
Spiral/helical CT with
IV contrast
Chest X-ray
ECG
D-dimer
Venous Ultrasonography
Pulmonary angiography
Perfusion lung scanning
Echocardiography
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The ABG/ A-a Gradient myth:
You must do an arterial blood gas and calculate thealveolar-arterial gradient. Normal A-a gradient virtually
rules out PE.
Reality:
The A-a gradient is a better measure of gas exchange thanthe pO2, but it is nonspecific and insensitive in ruling outPE.
ABG
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ABG
-Characteristically reveal hypoxemia, hypocapnia, and
respiratory alkalosis.
Data from the Prospective Investigation of Pulmonary
Embolism Diagnosis (PIOPED) indicate that, contrary to classic
teaching,.
arterial blood gases lack diagnostic utility for PE..!!
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D-dimer
-D-dimers are fibrinolytic products formed when
the fibrin within a clot is proteolyzed by plasmin.
-Highly nonspecific, but are highly associated with
thrombosis and thrombolysis.
- Negative ELISA has a >99% negative predictive value
-Qualitative
-Quantitative . (ELISA) Positive assay is > 500ng/ml
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Combing Clinical Probability & D-Dimer
Christopher Study1 (n = 3,306)
Dichotomized Wells score 4 D-Dimer 500 ng/ml
Negative predictive value > 99.5%
Useful in excluding PE in outpatientsSafe to withhold treatment
1. Van Belle A, et al. Effectiveness of Managing Suspected Pulmonary Embolism
Using an Algorithm Combining Clinical Probability, D-Dimer Testing, andCom uted Tomo ra h . JAMA 2006;295 2 :172-179
D-dimer
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D-dimer
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D-dimer
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ECG
-About 70 percent of patients with acute PE have ECG abnormalities.
-The most common ECG abnormalities of pulmonary embolism are
tachycardia and nonspecific ST-T wave abnormalities.
-The classic finding of right-sided heart strain demonstrated by an S1-Q3-T3 pattern is observed in only 20% of patients with proven
pulmonary embolism.
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Chest X-ray
Chest X-Ray Myth:
You have to do a chest x-ray so you can find Hamptonshump or a Westermark sign.
Reality:
Most chest x-rays in patients with PE are nonspecific andinsensitive
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CHEST RADIOGRAPH FINDINGS IN PATIENT WITHPULMONARY EMBOLISM
Result Percent
Cardiomegaly 27%Normal study 24%Atelectasis 23%Elevated Hemidiaphragm 20%
Pulmonary Artery Enlargement 19%Pleural Effusion 18%Parenchymal Pulmonary Infiltrate 17%
Chest X-ray
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CHEST X-RAY EPONYMS OF PE
Westermark's sign
A dilation of the pulmonary vessels proximal to the
embolism along with collapse of distal vessels,sometimes with a sharp cutoff.
Hamptons Hump
A triangular or rounded pleural-based infiltrate with theapex toward the hilum, usually located adjacent to thehilum.
Chest X-ray
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Chest X-ray
Westermark'ssign
Hamptons
Hump
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Rapidly gaining importance (risk stratify)
40 % have abnormalities:
RV pressure overload
McConnel sign:
Regional RV dysfunction
Apical wall motion remains normal
Hypokinesis of free wall
Echocardiography
l / f
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V/Q Scan
Perfusion: Tc-99M
Ventilation: Xenon
Underperfusion ~ V/Q mismatch
Ventilation/Perfusion Scan
- V/Q Scan
/
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Greatest limiting factors: Structural lung disease
Availability
Often non-diagnostic (60%!)1
Still useful: peripheral small/multiple PEs
1. The PIOPED Investigators. Value of the ventilation/perfusion scan in acute
pulmonary embolism: results of the Prospective Investigation of Pulmonary
Embolism Diagnosis (PIOPED).JAMA. 1990;263:2753-2759.
V/Q Scan
l/h l l h
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Spiral/helical CT with IV contrast
-Technical advances in CT scanning, including thedevelopment of multidetector-array scanners, have led to the
emergence of CT scanning as an important diagnostic
technique in suspected PE.
-Contrast-enhanced CT scanning is increasingly used as the
initial radiologic study in the diagnosis of pulmonary
embolism, especially in patients with abnormal chest
radiographs in whom scintigraphic results are more likely tobe nondiagnostic.
i l/h li l i h
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Findings of Acute PE
Intraluminal filling defect surrounded by
contrast
Ancillary findings that are suggestive:
Expanded unopicified vessels
Eccentric filling defects
Peripheral wedge-shaped consolidation
Oligaemia
Pleural effusion
Spiral/helical CT with IV contrast
S i l/h li l C i h IV
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Spiral/helical CT with IV contrast
Spiral computed tomography of the chest with contrast showing large
clot (black arrow) obstructing right main pulmonary artery
S i l/h li l CT i h IV
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The axial CT image (left) shows large pulmonary emboli bilaterally. The
pulmonary arteries from this image are magnified on the right to show
these emboli better (yellow arrows).
http://www.ceessentials.net/article12.html
Spiral/helical CT with IV contrast
S i l/h li l CT i h IV
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These two axial CT images show profound pulmonary emboli. On the left theembolus almost completely blocks the right pulmonary artery (yellow arrow).Right image show an extensive saddle embolus forming in both pulmonary
arteries and becoming extensive. Both of these types of pulmonary emboli are lifethreatening and require immediate medical attention .
http://www.ceessentials.net/article12.html
Spiral/helical CT with IV contrast
P l A i h
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Pulmonary Angiography
The clot appears as a filling defect (arrow)
http://www.webmm.ahrq.gov/case.aspx?caseID=14
-Is the definitive technique or gold
standard in the diagnosis of PE.
-A filling defect or abrupt cutoff of a
vessel is indicative of PE.
-Can detect emboli as small as 1 to 2
mm.
P l A i h
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Pulmonary Angiography
Diagnostic: filling defects
Secondary signs:
Cut-off of vessels
Segmental oligaemia
Prolonged arterial phase, slow filling Tapering of vessels
P l A i h
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http://www.nci.cu.edu.eg/lectures/pulmonary%20Embolism.pdf
filling defects
Pulmonary Angiography
E l ti f DVT
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Duplex Doppler
Compression Ultrasound
Venogram (diagnostic dilemmas)
MRI
Helical CT Venography (CTV)
Evaluation of DVT
Di ti A h
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Diagnostic Approach
CT experienced institutions CT inexperienced institutions
Modified Wells pretest probability scoring
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Modified Wells pretest probability scoring
Di ti A h
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Diagnostic Approach
CT experienced institutions:-When PE is suspected, the modified Wells criteria should be applied to determine if
PE is unlikely (score 4) or likely (score >4).
-Patients classified as PE unlikely should undergo D-dimer testing with a quantitative
rapid ELISA assay or a semiquantitative latex agglutination assay. The diagnosis of PE
can be excluded if the D-dimer level is 500 ng/mL should undergo CT-PA. A positive CT-PA confirms the
diagnosis of PE. Alternatively, a negative CT-PA excludes the diagnosis of PE.
-In those rare instances in which the CT-PA is inconclusive, either pulmonaryangiography or the diagnostic approach intended for institutions without experience
in CT-PA can be used.
Diagnostic Approach
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CT-based diagnostic strategy used in patients with suspected pulmonary embolism
CT experienced institutions:
Diagnostic Approach
Diagnostic Approach
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CT inexperienced institutions:-The Wells criteria are initially applied to determine whether the clinical probability
of PE is low (score 6).
-A ventilation-perfusion (V/Q) scan is then performed, with the following
combinations of outcomes possible.
Normal V/Q scan plus any clinical probability excludes PE
Low probability V/Q scan plus low clinical probability excludes PE High probability V/Q scan plus high clinical probability confirms PE.
-Any other combination of V/Q scan result plus clinical probability should prompt
either a pulmonary angiogram or serial lower extremity venous ultrasound exams.
Only the pulmonary angiogram is able to diagnose PE.
Diagnostic Approach
Diagnostic Approach
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CT inexperienced institutions:
Diagnostic Approach
VQ-based diagnostic strategy used in patients with suspected pulmonary embolism
Management
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Supportive care
Anticoagulation
Thrombolysis
Catheter based interventions
Surgical embolectomy
Inferior vena cava filters
Management
AHA definitions
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Massive PE: Acute PEwith
sustained hypotension (SBP
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Submassive PE: AcutePE without systemic
hypotension (systolic blood pressure 90mm
Hg) but with either RV dysfunction or
myocardial necrosis.
Low-risk PE: Acute PEand the absence of the
clinical markers of adverse prognosisthat
define massive or submassive PE.
AHA definitions
Anticoagulation
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-Is the mainstay of treatment.
Anticoagulation
AHA Recommendations for Initial Anticoagulation for Acute PE
Therapeutic anticoagulation with subcutaneous LMWH, IVor SC
UFH with monitoring, unmonitored weight-based
SC UFH, orsubcutaneous fondaparinux should be givento patients withobjectively confirmed PE and no contraindicationstoanticoagulation
Therapeuticanticoagulation during the diagnostic workupshouldbe givento patients with intermediate or high clinicalprobabilityofPE and no contraindications to anticoagulation
Anticoagulants
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Anticoagulants
Unfractionated heparin therapy
Low-molecular-weight heparin therapy
Fondaparinux
Warfarin therapy
Target INR = 2 - 3
Thrombolytic Therapy
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Thrombolytic Therapy
AHA Recommendations for Fibrinolysis for Acute PE
Fibrinolysis is reasonable for patients with massive acute PEandacceptable risk of bleeding complications
Fibrinolysis may be considered for patientswith submassiveacute PEjudged to have clinical evidence ofadverse prognosis(newhemodynamic instability, worsening respiratoryinsufficiency,severe RVdysfunction, or major myocardial necrosis)and lowrisk of bleeding
complications
Thrombolytic Therapy
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Thrombolytic Therapy
orrisk PE-with lowrecommended for patientsnotFibrinolysis issubmassiveacute PE withminor RV dysfunction, minor myocardialnecrosis,and no clinical worsening .
arrestrecommended for undifferentiated cardiacnotFibrinolysis is
Thrombolytic Therapy
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Contraindications for thrombolytic therapy
Thrombolytic Therapy
Thrombolytic Therapy
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A computed tomographic angiogram shows a large saddle embolus at the bifurcation of the
main pulmonary artery, with extension into the right and left pulmonary arteries (arrow in
Panel A). Following treatment with intravenous tissue plasminogen activator, the patient's
respiratory status dramatically improved over a period of several hours. Computed
tomography obtained approximately 24 hours later demonstrates resolution of the saddle
embolus (Panel B).
Thrombolytic Therapy
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Catheter-Based Interventions
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Percutaneous techniques to recanalize complete
and partial occlusionsin the pulmonary trunk or
major pulmonary arteries are potentiallylife-saving
in selected patients with massive or submassivePE.
In general, mechanical thrombectomy should be
limited to themain and lobar pulmonary arterialbranches
Catheter-Based Interventions
Surgical Embolectomy
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Emergency surgical embolectomy with
cardiopulmonary bypass hasreemerged as an
effective strategy for managing patients
withmassive PE or submassive PE with RVdysfunction when contraindicationspreclude
thrombolysis.
Surgical Embolectomy
Recommendations for Catheter
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Either catheter embolectomy and
fragmentation or surgical embolectomyis reasonable for
patientswith massive PE and contraindications to fibrinolysis
patients with massivePE who remain unstableafter receiving
fibrinolysis
patientswith submassive acute PE judged to have clinicalevidence
ofadverse prognosis (new hemodynamic instability,worsening
respiratoryfailure, severe RV dysfunction, or majormyocardial necrosis)
Catheter embolectomy andsurgical thrombectomy are not
recommendedfor patients withlow-risk PE or submassive acute PE with
minorRV dysfunction,minor myocardial necrosis, and no clinical
worsening.
Recommendations for Catheter
Embolectomy and Fragmentation
Inferior Vena Cava Filters
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Inferior Vena Cava Filters
An inferior vena cava filter, also IVC filter or Greenfield Filter a
type of vascular filter, that is implanted by interventional
radiologists or vascular surgeons into the inferior vena cava to
prevent fatal pulmonary embolism (PEs).
Inferior Vena Cava Filters
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Inferior Vena Cava Filters
Recommendations on IVC Filters in the
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Recommendations on IVC Filters in the
Setting of Acute PE
Adult patients with any confirmed acute PE (or proximal DVT)withcontraindications to anticoagulation or with active
bleedingcomplication
Anticoagulation should be resumed in patients
with an IVCfilteronce contraindications to anticoagulationor active
bleedingcomplications have resolved .
For patients with recurrent acute PE despite
therapeuticanticoagulation, it is reasonable to place an IVC filter
For DVT or PE patients who willrequire permanent IVC filtration(eg,
those with a long-termcontraindication to anticoagulation),it is
reasonable to selecta permanent IVC filter device
Recommendations on IVC Filters in the
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For DVT or PE patients with a time-limited indicationfor
anIVC filter (eg, those with a short-term
contraindicationtoanticoagulation therapy), it is reasonable
to select a retrievableIVC filter device
Placementof an IVC filter may be considered for patients
withacute PEand very poor cardiopulmonary reserve,
including thosewithmassive PE
An IVC filtershould not be used routinelyas an adjuvant
toanticoagulationand systemic fibrinolysis in the treatment
ofacute PE
Recommendations on IVC Filters in the
Setting of Acute PE
Resources
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Resources http://emedicine.medscape.com/article/4623
90-overview
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Thank You