gerber pulmonary embolism

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  • 1.Contemporary Management of Pulmonary Embolism Lowell I. Gerber M.D. AssociateProfessor of Medicine KCOM

2. PULMONARY EMBOLISM

  • Estimated 650,000 cases annually in the US
  • Third most common cause of death in US
    • 50,000 to 200,000 deaths per year
  • 15% of all in-hospital deaths
  • Difficult to diagnose
  • Approx. 10% of patients in whom diagnosis is established die within first 60 minutes

3. MASSIVEPULMONARY EMBOLISM

  • Estimated 10+% of all PE
  • 3-7X increased mortality over non-massive PE
    • UPET 36% vs 5%
    • ICOPER 58%vs 15%
    • MAPPET 31%

4. PULMONARY EMBOLISM PATHOLOGY 5. PULMONARY EMBOLISM PATHOPHYSIOLOGY 6. THE SPECTRUM OF PULMONARY EMBOLISM Right Ventricular Dysfunction Hemodynamic Instability Stable Hemodynamics and Cardiac Function 7. CLINICAL RISK FACTORS FOR VTE

  • AGE > 40
  • MAJOR SURGERY OR TRAUMA
  • IMMOBILIZATION
  • VENOUS STASIS
  • OBESITY
  • DIABETES
  • FRACTURE
  • VARICOSE VEINS
  • CHF , MI, CVA
  • PRIORHX VTE HIP
  • PREGNANCY / POSTPARTUM
  • CONTRACEPTIVES
  • CANCER
  • ANTIPHOSPHOLIPID AB SYNDROME

8. HERITABLE RISK FACTORS FOR VTE

  • FACTOR V LEIDEN MUTATION
  • HYPERHOMOCYSTEINEMIA
  • PROTEIN C DEFICIENCY
  • RESISTANCE TO ACTIVATED PROTEIN C
  • PROTEIN S DEFICIENCY
  • ANTITHROMBIN III DEFICIENCY

9. HERITABLE RISK FACTORS FOR VTE

  • PROTHROMBIN MUTATION G20210A
  • HEPARIN COFACTOR II
  • DYSFIBRINOGENEMIA
  • DYSPLASMINOGENEMIA

10. RISK STRATIFICATION VARIABLE HAZARD RATIO (95% CI) Age >70 years 1.6 (1.1-2.3) COPD1.8 (1.2-2.7) Systolic blood pressure 3days) or surgery in 4wks 1.5

  • Previous PE or DVT 1.5
  • Hemoptysis 1.0
  • Malignancy (Rxing or Rxed in last 6 mos) 1.0
  • >4 pts:Clinical probability of PE is likely
  • 4 or less pts:Clinical probability of PE is unlikely

Wells, et alThromb Haemost2000;83:416-420 12. MORTALITYPE/DVT IN ELDERLY INHOSPITAL1 YEAR 21%/ 3%39%/ 21% Kniffin et al.Arch Intern Med . 1994 Apr 25 13. CLINICAL PROFILE PE STEIN, P.D. ET AL.CHEST 100:598, 1991 SYMPTOMS FREQUENCY (%) DYSPNEA73 PLEURITIC PAIN66 COUGH37 LEG SWELLING / PAIN28 / 26SIGNS FREQUENCY (%) TACHYPNEA (>20/MIN)70 RALES51 TACHYCARDIA30 S4 / INCREASEDS224 / 23 14. CXR PULMONARY VASCULATURE ENLARGED RIGHT DESCENDING PULMONARY ARTERY WEDGE-SHAPED INFILTRATE OFTEN NORMAL 15. ELECTROCARDIOGRAM PULMONARY EMBOLISM T-wave inversion in leads III, aVF, or in leads V1-V4 QS in leads III and aVFIncomplete or complete right bundle branch block QRS axis > 90 or indeterminate axis Transition zone shift to V5 16. ELECTROCARDIOGRAM PULMONARY EMBOLISM

  • S1,Q3,T3 most specific
  • Normal or Sinus Tachycardia most frequent

17. LABORATORY TESTINGD-DIMER ELISA

  • Sensitive but nonspecific test for PE
  • High negative predictive value when concentrations 2.8 m/s
  • Lack of decreased inspiratory collapse of inferior vena cava

33. TRANS ESOPHAGEAL ECHOCARDIOGRAPHY AND PATENT FORAMEN OVALE inPULMONARY EMBOLISM

  • Patent foramen ovale detected on TEE is an important predictor of adverse outcome in patients with major pulmonary embolism.
  • These patients had a death rate of 33% as opposed to 14% in patients without PFO
  • There is significantly higher incidence of ischemic stroke (13% versus 2.2%; P=.02) and peripheral arterial embolism (15 versus 0%; P 14 days old).

87. SUMMARY

  • Further studies are needed to answer the questions regarding effectivenes and clinical benefit of the catheter-based approachand emergency thrombectomy compared to thrombolytics.

88. Protocol for the Treatment of Massive Pulmonary Embolism in Patients Who Have Contraindications to Thrombolytic Therapy using the Possis AngioJet System 89. Inclusion / Exclusion Criteria

  • Inclusion
  • Symptomatic massive PE
  • RV Dysfunction
  • Contraindications to thrombolysis
  • Recent PE 18
  • Exclusion
  • Severe Anemia
  • Inability to tolerate hemolysis
  • Chronic terminal illness
  • PE > 14 days
  • Inability to obtain informed consent or follow up

90. Procedure

  • Establish Diagnosis
  • Diagnostic Studies
    • VQ Lung Scan
    • Spiral CT
  • Echocardiogram for RV Function
  • Pulmonary Angiography
  • Rheolytic Thrombectomy
  • Follow Up 24 hours, at hospital D/C and 30 days

91. Protocol for the Treatment of Patients with Normotensive Submassive Pulmonary Embolism with Right Ventricular Dysfunction

  • Randomize Patients
  • Standard Care (anticoagulation) vs. Lytic Therapy
  • Subgroup patients with contraindications or high risk for bleeding with thrombolytics can be treated with AngioJet
  • Exclude patients with chronic terminal illness
  • Follow Up Assessment
    • Cardiopulmonary Treadmill Testing
    • VQ Lung Scan

92. Protocol for the Treatment of Patients with Normotensive Submassive Pulmonary Embolism with Right Ventricular Dysfunction:Follow-up Assessment and End-points

  • 30 day mortality
  • Bleeding complications
  • Thrombolytic dose and cost
  • Echo
  • V/Q lung scan
  • Cardiopulmonary Stress test

93. Contemporary Management of Pulmonary Embolism Lowell I. Gerber M.D.