diagnosis and management of pulmonary thromboembolism dr.vivekananthan d.a.,frca.,edic.,fficm.,

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Diagnosis and management of pulmonary thromboembolism

Diagnosis and management of pulmonary thromboembolismDR.VIVEKANANTHAN D.A.,FRCA.,EDIC.,FFICM.,OVERVIEWDiagnosis tests available and diagnostic strategies usedPrognostic assessmentManagement- therapeutic strategies and methods availableSpecial circumstances

Pulmonary thromboembolismVenous Thromboembolism (VTE) spectrum- DVT & PEMajor morbidity and mortalityNot uncommon Diagnosis could be Elusive

Epidemiology is difficult in PE due to patients being asymptomatic, and diagnosis could be incidental finding, and many a times initial presentation is death3Risk factors

Insidious, unprovoked- provoked due to Pregnancy, HRT, surgery, indwelling catheters, increasing age, cancer, immobility, 4pathophysiology

Main pathological cause for morbidity and mortality is the RV dysfunction 40-50 % blockade of the pulmonary circulation is necessary to cause circulatory collapse, pulmonary vasoconstriction induced by thromboxane A2, RV failure, 5Diagnosis- Symptoms galore!

Pollack et.al 2011pitfall amongst symptoms and signs30% patients with Confirmed PE do not have predisposing factors40% patients with confirmed PE do not have hypoxaemia20% patients with confirmed PE have normal alveolar arterial oxygen gradient40% patients with confirmed PE have sinus tachycardia on ECG rather than classical ECG changes59% of fatal PE were undiagnosed during life time

Acute PE- Initial diagnostic strategyWith shock and without shock- High risk PEModerate and low risk PEABC care supportive and immediate definitive treatment8Diagnosis -Assessing clinical probabilityWells ruleGeneva ruleThree group category -Low, intermediate, high risk groupingTwo group category- PE likely, PE unlikely grouping

Previous PE, surgery or fracture, DVT or leg swelling, heart rate, HAEMOPTYSIS, active cancer (7) are common parameters in both rules, age is included in Geneva rule- based on the scores they are grouped into three or two categories. Well validated 10% chance of having confirmed PE in low risk group and 12% risk of having confirmed PE in unlikely group9WELLS RULE

GENEVA RULE

Diagnosis- D-dimerPositive predictive value is lowNegative predictive value is highELISA derived assay Vs latex derived assay reliabilityUsefulness- can exclude PE in up to 30% of patients suspected with low or intermediate risk PE- (class I recommendation)Age adjusted D-dimer cut off value improved specificity by 10%, if not specificity decreases with ageD-dimer is increased by thrombosis- there is coagulation and fibrinolysis- fibrin is also produced by inflammation, trauma, bleeding, cancer, surgery, necrosis etc., - Diagnostic sensitivity of >95% for ELISA and 50 years, (specificity decreases with increasing age )12Diagnosis- CT pulmonary angiogram83% sensitivity and 96% specificity PIOPED II trialNegative predictive value for CTPA is >89-96% in intermediate and low risk groupSegmental clot presence confirms PE -(class I recommendation)CT venography combined with CTPA increases sensitivity from 83 to 90%, however specificity remains the sameIncidental CT diagnosis of PE is 1%Sub segmental PE incidence is 4.5% with lower clinical significance PIOPED II trial- multi detector MDCT- prospective investigation on pulmonary embolism diagnosis trial13Diagnosis- ventilation perfusion scintigraphyV/Q scan- technicium99 Well validated testSafe, less allergic,

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