Acute Pulmonary EmbolismRisk stratification & Management

September 2016

Dr Prithvi PuwarDNB Cardiology

Vijaya Hospital Chennai

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• Risk stratification

• Laboratory tests (D-dimer, Cardiac biomarkers)

• Imaging techniques (CTPA, V/Q scan, Echocardiogram)

• Therapeutic options (thrombolysis, IVC filter, Thrombectomy)

Todays discussion

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Risk stratification

• PERC Rule

• Wells score for PE

• Modified Geneva score for PE

• PESI Index

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PERC

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Kline JA, Mitchell AM, Kabrhel C, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004;2:1247–55.

Wells score for PE

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Geneva score for PE

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PESI to differentiate Int from Low

Risk

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Pulmonary Embolism Severity Index (PESI)

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Biomarkers

• Troponin ‐ released from right ventricle Injury

• Cardiac BNP ‐ released from cardiac myocytes in response to elevated pressures

RVD

*A normal troponin and BNP can safely exclude high risk patients with a negative

predictive value of 97-100%

• H-FABP (heart type fatty acid binding protein) – early marker for injury (good for

prognosis as well)

• NGAL (neutrophil gelatinase associated lipocalin) & Cystatin C – both indicating

kidney injury, also shown to have prognostic value

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D-dimer in PE

• D-dimer is a type of Fibrin degradation product

• Can be raised due to a number of reasons

• False positive D-dimer: infection, pregnancy, renal failure, post-operative

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– Qualitative

• Bed side RBC agglutination test

• Low Specificity and Sensitivity

– “SimpliRED D-dimer”

– Quantitative

• Enzyme linked immunosorbent assay “Dimertest”

• Positive assay is > 500ng/ml

• VIDAS D-dimer, 2nd generation ELISA test

• Specificity decreases with age above 80 to 10% so

age-adjusted cut-off points are used for thatMay 3, 2023 17

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ECG findings in PE

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Echocardiogram in PE

Recommendation for echo

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• Echocardiographic examination is not recommended as an element of elective diagnostic strategy in haemodynamically stable, normotensive patients with suspected PE.

• in a patient with suspected PE who is in a critical condition, bedside echocardiography is particularly helpful in emergency management decisions.

• In a patient with shock or hypotension, the absence of echocardiographic signs of RV overload or dysfunction practically excludes PE as a cause of haemodynamic compromise.

• The main role of echocardiography in non-high-risk PE is further prognostic stratification to the intermediate or low-risk category.

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• In a patient with shock or hypotension, the absence of echocardiographic signs of RV overload or dysfunction practically excludes

Ventilation-perfusion scanIndications:

- Renal failure- Pregnancy

Procedure:- Ventilation scan with Xenon inhalation- Perfusion scan with Tc99m labelled radioactive dye infusion- Scan V/Q- Result: unmatched V/Q

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Interpretation:

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Recommendation

• A normal perfusion scan is very safe for excluding PE.

• Although less well validated, the combination of a non-diagnostic V/Q scan in a patient with a low clinical probability of PE is an acceptable criterion for excluding PE.

• A high-probability V/Q scan establishes the diagnosis of PE with a high degree of probability

• In all other combinations of V/Q scan result and clinical probability, further tests should be performed

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CTPAIndications:

- Suspected PE

Contra-indications:- Renal failure- Pregnancy- Allergy to radio-contrast

1.7-5% risk of developing breast cancers (Hurwitz et al. 2007)

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Multidetector helical CTPA

• First line modality• Cover all chest with high spatial resolution in one breath• Detect peripheral smaller emboli• Detect other pathologies• Detect RV strain (straightening or leftward bowing of IV septum)

BUT• Radiation Exposure• # in renal failure and contrast allergy

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• Anticoagulation:– IV Heparin, S/C LMWH, Oral Warfarin

• IVC filter: If there is contra-indications for anti-coagulation

• Thrombolysis: tPA eg Alteplase, Tenectaplase

• Surgical procedures: Pulmonary embolectomy

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Treatment options

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High-Risk (Massive) PE • Definition: Acute PE with:– Cardiac arrest / hemodynamic instability– Sustained hypotension (systolic blood pressure 90 mm Hg for at

least 15 minutes OR requiring inotropic support not due to a secondary cause (arrhythmia, sepsis)

*Remember: The presence of “lots” of PE isn’t enough to call it “massive

• High-Risk PE therapy:– Systemic Anticoagulation ASAP– Supplemental oxygen for O2 sat <90%– Admit to the intensive care unit: Significant hypoxemia, Hemodynamic compromise

thrombolytic therapy– Mechanical ventilation for respiratory failure– For Hypotension: IVF, Vasopressor SupportMay 3, 2023 32

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Anticoagulation

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Recommendations for Initial Anticoagulation forRecommendations for Initial Anticoagulation for Acute PE Acute PE (AHA/ASC 2011, ACCP 2012) (AHA/ASC 2011, ACCP 2012)

• Therapeutic anticoagulation with SC LMWH, IV or SC UFH with monitoring, unmonitored weight-based SC UFH, or SC fondaparinux + VKA (till INR >2 for 24 hr) should be given to pts with objectively confirmed PE and no # to anticoagulation (1B)

Preferred than UFH except if # (renal impairment, with thrombolysis or can’t afford)May 3, 2023 37

Therapeutic parenteral anticoagulation during the diagnostic workup should be given to pts with intermediate (if diag. delay >4hrs) or high clinical probability of PE & no # to anticoagulation (2C)

Therapeutic parenteral anticoagulation during the diagnostic workup is not given in low probability (if diag. not delayed than 24 hrs) (2C)

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The results of the trials (RE-COVER, RECORD-3, EINSTEIN-PE, AMPLIFY, Hokusai-

VTE) using NOACs in the treatment of VTE indicate:

These agents are non-inferior (in terms of efficacy) and possibly safer

(particularly in terms of major bleeding) than the standard heparin/VKA

regimen.

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Optimal Duration of Anticoagulation Optimal Duration of Anticoagulation

ACCP 2012May 3, 2023 40

Thrombolysis• Indications:

– Massive PE

– Sub-massive PE where risk of bleeding low (in RVD?!)

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•Drugs:

(Most rapid)

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Fibrinolysis in PE: Evidence

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No survival benefit

No increase in ROSC

Increased risk of ICH among survived

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ACC/AHA & ACCP RecommendationsACC/AHA & ACCP Recommendations

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IVC filter• Indications:

- DVT with massive pulmonary embolus

- Recurrent PE not treatable with anticoagulation

- Absolute contra-indications for anti-coagulation

- Trauma patients

• Not used in: - DVT in distal vessels / nonmassive DVT, DVT not involving

proximal vessels.

- Patients scheduled for systemic thrombolysis, surgical embolectomy, or pulmonary thrombendarterectomy.

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• Complications associated with IVC filterComplications associated with IVC filter

Early complications

• Device malposition (1.3%)

• Hematoma (0.6%)

• Air embolism (0.2%)

• Inadvertent carotid artery

puncture (0.04%)

• Arteriovenous fistula

(0.02%)

Late complications

• Recurrent DVT (21%)

• IVC thrombosis (2% to

10%),

• IVC penetration (0.3%)

• Filter migration (0.3%)

• Recurrent PE (2-5%)

• Fatal PE (0.7%)

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• Various inferior vena caval filters:Various inferior vena caval filters:

A Greenfield filterA Greenfield filter

B Titanium Greenfield filter B Titanium Greenfield filter

C Simon-Nitinol filter C Simon-Nitinol filter

D LGM or Vena Tech filter D LGM or Vena Tech filter

E Amplatz filter E Amplatz filter

F Bird’s Nest filterF Bird’s Nest filter

G G Günther Tulip filter (2000)Günther Tulip filter (2000)

**Located below renal veinsLocated below renal veins

(Adapted from Becker et al.)May 3, 2023 67

Retrievable IVC filters: Günther Tulip filter, Celect filter, OptEase filter, Bard G2 filter, Crux filter, and ALN filter.

Recommendations on IVC Filters in the Recommendations on IVC Filters in the Setting of Acute PESetting of Acute PE

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Catheter-Based InterventionsCatheter-Based Interventions

• Performed as an alternative to thrombolysis When there are contraindications When emergency surgical thrombectomy is unavailable or

contraindicated Hybrid therapy that includes both catheter-based clot

fragmentation and local thrombolysis is an emerging strategy

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• Categories of percutaneous intervention

Suction thrombectomy with aspiration catheters

Thrombus fragmentation with pigtail or balloon catheters

Rheolytic thrombectomy with hydrodynamic catheters (saline jet or

drug)

Rotational thrombectomy

Conventional catheter directed thrombolysis (drugs)

U/S accelerated thrombolysis

Pharmaco-mechanical thrombolysis (combined technique)

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Catheter-directed therapy: OptionsCatheter-directed therapy: Options

Local delivery of streptokinase

-- Extensive lysis (by perfusion scan and pulmonary arteriography at 12 to 24

hour follow-up)

Intrapulmonary versus peripheral route

-- no advantage over the intravenous route

Direct delivery into clot

--Enhanced thrombolysis, relatively low doses (in an animal model of PE)

-- Could prove advantageous over the intravenous route

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Angiojet Rheolytic

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• Side Effects (2%)

Death from worsening RV failure,

Distal embolization,

Pulmonary artery perforation with lung hemorrhage,

Systemic bleeding complications,

Pericardial tamponade,

Heart block or bradycardia,

Haemolysis,

Contrast-induced nephropathy, and

Puncture-related complications

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Surgical EmbolectomySurgical Embolectomy

• When contraindications preclude thrombolysis

• Surgical excision of a right atrial thrombus

• Rescue patients whose condition is refractory to thrombolysis

• Older case series suggest a mortality rate between 20% and 30%

• In more recent studies, patients underwent surgical embolectomy in a 4-

year period, with a 96% survival rate

Am Heart J 2011;134:479-87May 3, 2023 77

Recommendations (AHA – ACCP)Recommendations (AHA – ACCP)

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PE in Pregnancy

• D-dimer has high negative predictive value. False positive result is common

• V/Q scan is preferred technique

• CTPA can be done if V/Q is inconclusive

• Preferred treatment option: LMWH

• Warfarin is contraindicated

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PE in Cancer

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