1. PULMONARY EMBOLI Kenney Weinmeister M.D.

2. PULMONARY EMBOLI w Over 500,000 cases per year. w Results in 200,000 deaths. w Mortality without treatment is 30%. w With therapy mortality drops to 2-8%.

3. RISK FACTORS FOR THROMBOEMBOLIC DISEASE w Obesity has an increased risk factor of 2.9. w Tobacco use: 25-35 cigarettes/day risk factor is 1.9. >35 cigarettes/day risk factor is 3.3. w Hypertension caries a risk factor of 1.9. w Factor V Leiden mutant is seen in 40% of idiopathic thromboembolic disease.

4. Signs And Symptoms w Tachypnea 70% w Rales 51% w Tachycardia 30% w S4 24% w Accentuated P2 23% w Dyspnea 73% w Pleuritic Chest Pain 66% w Cough 37% w Hemoptysis 13%

5. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J 2000 MASSIVE PE DEFENITION w Systolic BP less than 90 mmHg w Drop in systolic BP of > 40 mmHg from baseline for > 15 minutes, not explained by hypovolemia, sepsis, or a new arrhythmia w Two or more lobar arterial occlusions

6. MASSIVE PE PATHOPHYSIOLOGY w Increased afterload on right ventricle Occlusion of vascular bed Vasoconstriction w Elevated pulmonary artery pressure 50% obstruction before mean PAP rises w Right ventricle fails 75% obstruction of vascular bed w Death

7. DIAGNOSIS w ECG w ABG w CHEST X-RAY w D-dimer: ELISA method D-dimer < 500ng/ml has a negative predictive value of 95 to 99%. Turbidimetric D-dimer

9. D-dimer w Unidirectional. w A negative quantitative rapid ELISA result is as diagnostically useful as a normal V/Q scan or negative venous dopplers. w Unlikely to be helpful in patients with recent surgery (within three months) or with malignancy.

10. ECHOCARDIOGRAPHY w RV dysfunction w Mobile cardiac emboli were seen in 18% of 130 patients with massive PE w Prospective study of 317 pts, 27% had RV dysfunction on Echo. Mortality with RV dysfunction 13%, without 0.9% Heart 1997

11. DIAGNOSIS: Ventilation Perfusion Scan w High probability: > 2 Large segmental defects > 2 Moderate segmental defects with 1 Large > 4 Moderate segmental defects w Intermediate probability: not falling into low or high probability.

12. DIAGNOSIS: Ventilation Perfusion Scan w Low probability: Nonsegmental perfusion defects. Single moderate mismatched segmental perfusion defect with normal cxr. Large or moderate segmental defects with matching defects. > 3 small segmental perfusion defects. w Normal: no perfusion defects.

14. Venous Doppler w B-Mode compression ultrasound: 6 level one studies; Sensitivity 89 - 100% Specificity 86 - 100% Positive Predictive Value 92 - 100% Negative Predictive Value 75 - 100% w Duplex US and Color flow doppler US have similar results.

15. PULMONARY ANGIOGRAPHY w Gold standard. w Mortality 0.2 - 0.5% w Morbidity 1 - 4%

16. SPIRAL COMPUTED TOMOGRAPHY w Greatest sensitivity for emboli in the main, lobar or segmental pulmonary arteries. w Only level 2 studies which show: Sensitivity 60 -100% Specificity 78 - 97%

17. Lancet 2002 Dec 14;360(9349):1914-1920 Spiral Computed Tomography w 1041 patients, anticoagulation withheld for negative CTA and dopplers. 360 (34%) dx with PE. 55 had + dopplers and negative CTA. 76 pts high probability PE but negative CTA & dopplers 4 had + V/Q or PAG. 507 not treated, 9 (1.8%) had TED at f/u.

18. Radiology 2000 May;215(2):535-42 Spiral Computed Tomography w 548 pts negative or low probability V/Q or negative CTA. PE found in 2 (1%) of 198 pts with neg CTA, 0 pts of 188 with neg V/Q, and five (3%) of 162 pts with low prob V/Q.

20. TREATMENT w Anticoagulation w Thrombolitics w IVC filter w Thrombectomy Catheter Surgery

21. ANTICOAGULANTS w Heparin w Low molecular weight heparin w Direct thrombin inhibitors w Factor Xa inhibitors w Coumadin

23. HEPARINS w Heparin dose on weight base w LMWH Some trials illustrate safety and efficacy of outpatient therapy or initiation of in hospital use and discharge on coumadin and LMWH.

24. Direct Thrombin Inhibitors w Hirudin w Lepirudin w Argatroban w Ximelagatran w Bivalirudin

25. Factor Xa Inhibitors w Fondaparinux w Razaxaban

26. DURATION OF THERAPY BY RISK FOR RECURRENCE w First event, age < 60 w First event, age > 60 or idiopathic disease w Recurrent event or first event with a nonreversible risk factor w 3-6 months w 6-12 months w 12 months to lifetime

29. INFERIOR VENA CAVA FILTER w No large studies have been performed to evaluate the impact on recurrence of PE. w No large prospective studies have been performed with regards to safety and efficacy. w Mortality 0.1 to 0.2% w Morbidity up to 18% risk of thrombosed IVC.

30. CONCLUSION w The diagnosis of PE is difficult and cannot be made on clinical criteria. w Large clinical trials are needed to evaluate the new imaging techniques as well as new diagnostic tests. w Failure to diagnose continues to be one of the largest causes of malpractice claims.