PULMONARY EMBOLI

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PULMONARY EMBOLI

• Kenney Weinmeister M.D.

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PULMONARY EMBOLI

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

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RISK FACTORS FOR THROMBOEMBOLIC DISEASE

• Obesity has an increased risk factor of 2.9.
• Tobacco use
• 25-35 cigarettes/day risk factor is 1.9.
• gt35 cigarettes/day risk factor is 3.3.
• Hypertension caries a risk factor of 1.9.
• Factor V Leiden mutant is seen in 40 of
  idiopathic thromboembolic disease.

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Signs And Symptoms

• Tachypnea 70
• Rales 51
• Tachycardia 30
• S4 24
• Accentuated P2 23

• Dyspnea 73
• Pleuritic Chest Pain 66
• Cough 37
• Hemoptysis 13

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MASSIVE PE DEFENITION

• Systolic BP less than 90 mmHg
• Drop in systolic BP of gt 40 mmHg from baseline
  for gt 15 minutes, not explained by hypovolemia,
  sepsis, or a new arrhythmia
• Two or more lobar arterial occlusions

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MASSIVE PE PATHOPHYSIOLOGY

• Increased afterload on right ventricle
• Occlusion of vascular bed
• Vasoconstriction
• Elevated pulmonary artery pressure
• 50 obstruction before mean PAP rises
• Right ventricle fails
• 75 obstruction of vascular bed
• Death

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DIAGNOSIS

• ECG
• ABG
• CHEST X-RAY
• D-dimer
• ELISA method D-dimer lt 500ng/ml has a negative
  predictive value of 95 to 99.
• Turbidimetric D-dimer

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D-dimer

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

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ECHOCARDIOGRAPHY

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

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DIAGNOSIS Ventilation Perfusion Scan

• High probability
• gt 2 Large segmental defects
• gt 2 Moderate segmental defects with 1 Large
• gt 4 Moderate segmental defects
• Intermediate probability not falling into low or
  high probability.

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DIAGNOSIS Ventilation Perfusion Scan

• Low probability
• Nonsegmental perfusion defects.
• Single moderate mismatched segmental perfusion
  defect with normal cxr.
• Large or moderate segmental defects with matching
  defects.
• gt 3 small segmental perfusion defects.
• Normal no perfusion defects.

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Venous Doppler

• B-Mode compression ultrasound
• 6 level one studies
• Sensitivity 89 - 100
• Specificity 86 - 100
• Positive Predictive Value 92 - 100
• Negative Predictive Value 75 - 100
• Duplex US and Color flow doppler US have similar
  results.

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PULMONARY ANGIOGRAPHY

• Gold standard.
• Mortality 0.2 - 0.5
• Morbidity 1 - 4

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SPIRAL COMPUTED TOMOGRAPHY

• Greatest sensitivity for emboli in the main,
  lobar or segmental pulmonary arteries.
• Only level 2 studies which show
• Sensitivity 60 -100
• Specificity 78 - 97

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Spiral Computed Tomography

• 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.

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Spiral Computed Tomography

• 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.

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TREATMENT

• Anticoagulation
• Thrombolitics
• IVC filter
• Thrombectomy
• Catheter
• Surgery

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ANTICOAGULANTS

• Heparin
• Low molecular weight heparin
• Direct thrombin inhibitors
• Factor Xa inhibitors
• Coumadin

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HEPARINS

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

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Direct Thrombin Inhibitors

• Hirudin
• Lepirudin
• Argatroban
• Ximelagatran
• Bivalirudin

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Factor Xa Inhibitors

• Fondaparinux
• Razaxaban

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DURATION OF THERAPY BY RISK FOR RECURRENCE

• First event, age lt 60
• First event, age gt 60 or idiopathic disease
• Recurrent event or first event with a
  nonreversible risk factor

• 3-6 months
• 6-12 months
• 12 months to lifetime

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INFERIOR VENA CAVA FILTER

• No large studies have been performed to evaluate
  the impact on recurrence of PE.
• No large prospective studies have been performed
  with regards to safety and efficacy.
• Mortality 0.1 to 0.2
• Morbidity up to 18 risk of thrombosed IVC.

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CONCLUSION

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

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