VENOUS THROMBOSIS & PUL.EMBOLISM : PROF.DR. MUHAMMAD AKBAR CHAUDHARY M.R.C.P. (U.K.) F.R.C.P. (E) F.R.C.P. (LONDON) F.A.C.C DESIGNED AT A.V. DEPT F.J.M.C. BY RABIA KAZMI

VENOUS THROMBOSIS & PUL. EMBOLISM :  RISK FACTORS :  Immobility  Age > 40 years  Previous H/O D.V.T  Varicose veins  Obesity  Malignant diseases  Pregnancy  Puerperium  Oral contraceptives

 Surgery  Trauma  Myocardial infarction  Heart failure  Polycythemia  Thrombocythemia  Connective tissue disease  Congenital coagulation disorders VENOUS THROMBOSIS & PUL. EMBOLISM :(cont)

RISK FACTORS OF VENOUS THROMBOEMBOLISM

PULMONARY EMBOLISM ; Acute Chronic Minor Massive

PULM. EMBOLISM : PRESENTATION BY THREE CLINICAL SYNDROMES ; 1) PULM. INFARCTION/OR HAEMORRHAGE; Most common presentation ( >50% of patients of pulm. embolism ), Abrupt pleuritic chest pain with or without dyspnea is classic symptom, Haemoptysis occurs in minority of patients.

ON EXAMINATION: Patient has tachypnea No signs of Rt heart failure. Examination of lungs shows rales, wheeze, pleural effusion & may be pleural rub, D.V.T evidence is rare D.D : Viral & Bacterial pneumonitis

2) ACUTE COR-PULMONALE :  Presentation is dramatic, It occurs when pulm. embolism is massive to obstruct 60-75% of pulm. circulation. In response to Ac pulm. embolism, there is increased C. O & increased R.V systolic pressure to overcome increased resistance in pulm. circulation, The normal Rt ventricle can acutely increase its systolic pressure to about mmHg, Acute increase in pressure beyond this level causes Rt V dilatation & failure, decrease C.O.P, hypotension & cardiac arrest  patient presents with: Acute dyspnea, syncopy & cardiac arrest PULMONARY EMBOLISM ;

PULMONARY EMBOLISM ACUTE CORPULMONALE ON EXAMINATION  There is tachypnea, tachycardia and hypotension, signs of acute R.V. failure  Lungs are clear  D.V.T. may be present D/ DIAGNOSIS  Acute myocardial infarction  Hypovolemia  sepsis

PULMONARY EMBOLISM 3.) ACUTE UNEXPLAINED DYSPNEA  Diagnosis most difficult with sub-massive Pul. Embolism, who do not develop pul. Infarction E.C.G. & X-ray chest may be normal  D.V.T. may be present  Only physical signs may be tachyapnea, tachycardia & anxiety D.D  L.V.F  Pneumonia  Hyperventilation syndrome

CLINICAL DIFFERENCE BETWEEN THE VARIOUS PRESENTATIONS OF PULMONARY EMBOLISM Acute minor Acute major Chronic DyspnoeaMildSevereChronic, progressive Chest painPleuriticAcute, dull, central Exertional, dull, central TachycardiaMildUsually marked Variable Blood pressure NormallowNormal until late CyanosisNoCommon OdemaNoNot acutelyCommon

CLINICAL DIFFERENCE BETWEEN THE VARIOUS PRESENTATIONS OF PULMONARY EMBOLISM (cont) Acute minorAcute majorChronic Jugular venous pressure NormalRaised Heart soundsNormalS3S3,S4, P2+ Chest Radiology Often normalUsually abnormal Abnormal ECGUsually normalUsually abnormal Abnormal Systolic pulmonary artery pressure Normal30-50 mm Hg>70 mm Hg

Pulmonary embolism Investigations  X-ray chest  E.C.G  Arterial blood gases  Ventilation/perfusion lung scan  Pul. Angiography  Venography  Investigations for malignancy

Pulmonary embolism  Treatment  Prophylaxis  Treatment of D.V.T. & minor P.E  Treatment of large & massive P.E.

ETIOLOGY OF CHRONIC COR-PULMONALE MECHANISIM OF PULMONARY HYPERTENSION 1. Hypoxic vasoconstriction A. Chronic bronchitis and emphysema, cystic fibrosis B. Chronic hypoventilation 1. Obesity 2. Sleepapnea 3. Neuromuscular disease 4. Chest wall dysfunction C. High-altitude dwelling and chronic mountain sickness (Monge’s Disease)

2. Occlusion of pulmonary vascular bed A. Pulmonary thromboembolism, parastic ova, tumor emboli B. Primary pulmonary hypertension C. Pulmonary venocclusive disease D. Fibrosing mediastinitis, mediastinal tumor E. Pulmonary angitis from systemic disease 1. Collagen vascular diseases 2. Drug-induced lung diseases 3. Necrotizing and granulomatous arteries

3. Parenchymal disease with loss of vascular surface area A. Bullous emphysema, ά 1 antiproteinase deficiency B. Diffuse bronchiectasis, cystic fibrosis C. Diffuse interstitial disease 1. Pneumoconioses 2. Sarcoid, idiopathic, pulmonary fibrosis, histiocytosis X 3.Tuberculosis,chronic fungal infection 4. ARDS 5. Collagen vascular disease (immune lung disease) 6. Hypersensitivity pneumonitis