PULMONARY EMBOLISM PROF. DR. YESARİ KARTER KARTER
Pulmonary Embolism: Impaction of material into branches of the pulmonary arterial bed
Mortality death/year (decreasing) Hospitalisation: /year Male>Female American Africans old > young
RISK FACTORS - inherited - acquired
Inherited Risk Factors Family History (+) Acquired risk factor (-) Prior deep venous thrombosis
Inherited Risk Factors (2) -Antithrombin III deficiency -Protein C deficiency -Protein S deficiency -Protein C resistance (Factor V Leiden) -Hyperhomocystinemi -Abnormal fibrinogen -Abnormal fibrinolytic system
Acquired Risk Factors -surgery or trauma of pelvis/lower extremities -immobilization -surgery with >30 min general anesthesia -local tissue trauma and vessel destruction -pregnancy especialy in the puerperism and after cesarian section -estrogen therpy
Acquired Risk Factors (II) -Age > 40 -Malignity -Obesity -Heart Failure -Myocard infarction
Acquired Risk factors (III) -Prior DVT -Nephrotic Syndrome -Antiphospholipid Syndrome -PNH -Waldenström
Thromboembolic risk of the patient -Risk of the patient (acquired / inherited) -Risk of the clinical condition
Diagnose -Young patient -Family history (+) -Acquired risk factors (-) ___ inherited
Symptoms -Chest pain -Pleuritic pain -Dyspnea -Cough -Hemoptysis -Syncope
Laboratory Standart test ECG Chest rontgenography Arterial blood gases Echocardiography Imaging venous thrombus Imaging pulmoner emboli
Standart tests -Leucocytosis (infarctuse) -ESR increases -D-Dimer increases low---- Exclusion of PE
ECG Nonspesific changes -Massive emboli-----RV load Differential diagnosis -Myocardial infarctuse -Accelere atrial rythm Typical findings -RV strain -T (-) and or ST elevation (V1-3) -P pulmonale (right axis) -S1Q3T3
Chest Radiography Usually nonspesific Not sensitive or specific Proximal, large segmental artery Multiple small segmental artery
Chest Radiography (II) -Atelectasis -Elevation of the hemidiaphragm -Pleural efusion -Dilatation of the main branches of PA -Paranchymal densities (in the lower lung fields, pleural based) -Zones of oligemia
Arterial Blood Gases Acute PaCO2 decreases Massive PaO2 decreases Submassive Normal / Nearnormal
Echocardiography -Shows emboli in main pulmonary arteries, but not in lober and segmentary arteries -Dilated hypokinetic RV -Distorsion of the interventricular septum in diastole -Tricuspid regurgitation associated with increase in systolic pressure in pulmonary artery
Deep Vein Thrombosis -90% of PE originates from DVT (poplitea or proximal leg veins) -leg pain or swelling -Homan’s sign -signs of infection in subcutan veins
Deep Vein Thrombosis -Phlebography -Doppler
Imaging pulmonary emboli -Chest radiography -Ventilation-Perfusion Lung Scan -Pulmonary angiography -hCT -MR angiography
Ventilation-Perfusion Lung Scan Perfusion (-) and Ventilation (+) ---PE Perfusion (N) and Clinical sym and signs (N) ----PE excluded Low probability PVLS and low probability of clinical sym and signs ----PE excluded High probability PVLS and high probability of clinical symp and signs ---- Anticoagulation
Clinical Probability of acute PE -High Probability (80-100%) Risk factors (+) Dyspnea Tachypnea Chest pain Radiology (+) PaO2 decreases P (A-a)O2 increases -Intermediate Probability (20-79%) -Low Probability (1-19%) Risk Factors (-) Clinical and laboratory findings can be explained
D ichotomous clinical probability assesment: D ichotomous clinical probability assesment: PE likely > 4 PE likely > 4 Pe unlikely < 4 or = 4 Pe unlikely < 4 or = 4
PE likely h CT PE likely h CT normal----exclude normal----exclude findings (+)----PE findings (+)----PE indeterminate----LE US indeterminate----LE US PA PA PE unlikely-----D-dimer(+) PE unlikely-----D-dimer(+) h (CT) h (CT) D-dimer(-) D-dimer(-) exclude PE exclude PE
Pulmonary Angiography Gold standart İmages PE in subsegmental and peripheral arteries
hCT -two dimensional angiographic image -specifity 90% -dimension of the emboli -mediastinal and parenchymal patologies
MR Angiography Sensitivity-70 – 90 % Specifity- 77 – 100 % (Central arteries) Also asseses RV function
Treatment -to prevent death -to reduce morbidity -to prevent pulmoner hypertension progresing due to thromboemboli
Treatment (II) Supportive -Oxygen -IV liquid -Vasopressors
Anticoagulation -unfractioned heparin -LMWH -Thrombolysis -Embolectomy
Unfractioned Heparin IV 5000 U bolus U/kg aPTT- twice the control value -Thrombocytopeni early: thrombocyte agregation slight, reveresible, no need to stop late: antibodies against trombocytes arterial and venous thromboemboli -Osteopeni
LMWH -long acting -less binding to plasma protein -greater bioavailibity -no need monitorisation
Prognosis -Mortality rate – 30% -Depends on associated pathology -Resolution – 5 days 36% 2 weeks 52% 3 months 73% Pulmonary hypertension recurrent microemboli (rare)
Secondary prevention UFH + oral anticoagulan (6 months) LMWH SC + oral anticoagulan (6 months ) LMWH (pregnancy) Recurrance / unknown origin / permanantly increased risk (throughout life)
Thrombolysis Massive pulmoner emboli with hemodynamic instability -streptokinase -urokinase -t-PA **serious bleeding
REFERENCES: Agnelli G. Anticoagulation in the prevention and treatment of pulmonary embolism.Chest ; Agnelli G. Anticoagulation in the prevention and treatment of pulmonary embolism.Chest ; BellWR,Simon TL; DeMets DL. The clinical features of massive and submassive pulmonary embolism. Am J Med 1977; 62: BellWR,Simon TL; DeMets DL. The clinical features of massive and submassive pulmonary embolism. Am J Med 1977; 62: Braunwald E. Pulmonary embolism. Braunwald’s heart disease. Braunwald (ed)Philedalphia. WB Saunders Braunwald E. Pulmonary embolism. Braunwald’s heart disease. Braunwald (ed)Philedalphia. WB Saunders Herold CJ, Bankier AA, Burghaiber OC, Minar E, Watzke HH. Pulmonary Embolism. Comprehensive Pulmonary Medicine. Albert R, Spiro S, Jett J (eds). Harcaurt Brace and Company Limited London Herold CJ, Bankier AA, Burghaiber OC, Minar E, Watzke HH. Pulmonary Embolism. Comprehensive Pulmonary Medicine. Albert R, Spiro S, Jett J (eds). Harcaurt Brace and Company Limited London Hyers TH. Diagnosis of pulmonary embolism. Thorax 1995; 50: Hyers TH. Diagnosis of pulmonary embolism. Thorax 1995; 50: Lane D, Manucci PM, Bauer KA, et al. Inherited thrombophilia: Part I.Thromb Haemost 1996;76: Lane D, Manucci PM, Bauer KA, et al. Inherited thrombophilia: Part I.Thromb Haemost 1996;76: Remy -Jerden M, Remy J,Deschildre F. Diagnosis of pulmonary embolism with spiral CT: comparison with pulmonary angiography and scintigraphy. Radiology 1996; 200(3): Remy -Jerden M, Remy J,Deschildre F. Diagnosis of pulmonary embolism with spiral CT: comparison with pulmonary angiography and scintigraphy. Radiology 1996; 200(3):