Pulmonary Embolism

Manny Mathew, M.D, FCCP

Pulmonary/Critical Care .

Objectives 1. Pretest Probability for DVT/PE (Wells Criteria, Geneva

Score) 2. D-Dimer, when is it appropriate and how to Interpret 3. Specificity and Sensitive US Doppler LE Venogram VQ Scan CT Angiogram 4. Severity of PE and Indications for Thrombolytic Therapy 5. Indications for IVC filter

Case • 65 y/o M with CC of R side CP, SOB x 1 day • No leg swelling

• Recent travel to Taiwan

Case • O/E: 94% RA, P 105, RR26, T 99.5 • EXAM: normal

Labs • CBC: nml • CMP: nml

• EKG: sinus tachycardia

• CPK, Trop: nml

• D DIMER: 520 (nml less than 500)

• ABG (RA): P02 80, Ph 7.45, PCO2 35

Based on His History

• His Clinical Probability based on Modified Wells criteria or Geneva Criteria would be?

• A. High • B. Moderate • C. Low

Based on His History

• His Clinical Probability based on Modified Wells criteria or Geneva Criteria would be?

• B. Moderate

Clinical Diagnosis

PreTest Probability Of DVT: WELLS Score Active Ca (6m) 1 LE Paralysis, Paresis 1 Bedridden x 3d, Surg in past 4wks 1 Local Tenderness 1 Entire Leg Swelling 1 Calf Swelling 1 Pitting edema 1 Collateral Superficial Veins 1 Alternate Diag more likely -2

High Probability > 3 Moderate Probability 1-2 Low Probability 0

Geneva Score Age 60-79 >79

1 2

Prior DVT/PE 2

Recent Surg or Malignancy

3

HR > 100 1

PaCO < 36 36-39

2 1

Pa02 < 50 50-60 61-72 73-83

4 3 2 1

Atelectasis Elev hemidiaphragm

1 1

<4 Low risk

5-8 Intermediate Risk

>9 High Risk

0- 3 pts - low prob 4-10 pts – intermed Prob >11 pts - high probability

Signs & Symptoms of Radiographically Proven PPE

Diagnostic Tests

• Clinical • Labs: D Dimer, ABG, BNP, Troponin • CXR • EKG • Chest CT • V/Q Scan • Echocardiography • Pulmonary Angiography

D-dimer • 1st described in 1971

• Measures Fibrin Degradation Products

• Sensitivity = 95-100% • Specificity = 34% • NPPV = 95%

• In general if a pt does not have DVT/PE.. the D

Dimer will be normal

D Dimer

D Dimer |

------------------------------------------------- ELISA Latex Aglut -quantitative -quantitative -qualitative -qualitative

D Dimer

1. ELISA or Quantitative Rapid Elisa = (Sens 95%) = takes 10min

2. Qualitative ELISA or Quantitative Latex

Agglutination (sens = 90%) 3. Erythrocyte Agglutination sens 82%

D-Dimer

• D Dimer is not specific so……………….. NOT useful as stand alone test

• Very Useful when coupled Wells Criteria or Geneva Score in ruling out PE

• A negative Dimer + Low Pre Test Probability by Wells or Geneva = Rules out PE in > 95% cases

ABG

• Stein et al; CHEST 1995

• 280 pts with Acute PE

• 25% had nml PaO2 • 11-14% had nml A-a gradient

BNP and Troponin

• BNP = can be marker of RV dysfunction • BNP > 100ng increased mortality 6x • BNP > 600ng/dl incr mortailty 16x

• Elev of Trop > .07 also assoc with incr

mortality. No aid in Diagnosis

EKG • Sinus Tachycardia

• Atrial arrhythmias • RBBB • Inv T Waves in Pre-cordial Leads

• S1,Q3, T3

CXR

• Nonspecific

• Normal • Oligemia [Westermark Sign (1938)]

• Hemorrhage/infarct [Hamptons Hump (1940)]

• Effusion • Atelectasis

All of the Following are True EXCEPT

A. The Normal PO2 excludes PE B. The most common CXR findings are

nonspecific (ateletasis) C. An elevated BNP in the setting of PE is

assoc with increased mortality D. The Presence of a new RBBB on EKG

indicates RV strain

All of the Following are True EXCEPT

A. The Normal PO2 excludes PE

Diagnosis and Treatment Of PE Objectives

1. Pretest Probability for DVT/PE (Wells Criteria, Geneva Score)

2. D-Dimer, when is it appropriate and how to Interpret 3. Specificity and Sensitive US Doppler LE Venogram VQ Scan CT Angiogram 4. Indications for Thrombolytic Therapy 5. Indications for IVC filter

LE USS in DVT

• Abnormal Vein Compressibility

• Abnormal Doppler Flow

• Echogenic Band • Abnormal change in

diameter with Valsalva

The most specific and sensitive USS criteria for Proximal DVT is ?

A. Abnormal Vein Compressibility B. Abnormal Doppler Flow C. Echogenic Band D. Abnormal change in diameter with Valsalva

The most specific and sensitive USS criteria for Proximal DVT is ?

A. Abnormal Vein Compressibility

LE USS

• A normal LE USS exclude DVT in 98% of pts

• A repeat normal LE USS 7d later exludes DVT in 99% of pts

• Limitation: illiac and femoral V not seen

LE USS + PE

Will be normal or

negative in 30% of cases

**Useful Adjunct to

Low Probability Pt**

Based on The Clinical Pretest Probability of the aforementioned Patient The next best

step would be? A. LE USS + D-Dimer B. VQ Scan C. VQ Scan + LE USS D. CT Angiogram Chest

Based on The Clinical Pretest Probability of the aforementioned Patient The next best

step would be? D. CT Angiogram Chest

CT Angio Conventional • Patient Moves Down Scann er

• Exam takes 30sec

• Breathing Artifacts

removed • Best for PE, Aortic

Dissections, AVMs

• Patient Sedentary and Scanner moves

• Takes several minutes • Breath Holding required

• Parenchymal lung

disease

SPIRAL CHEST CT

• Mullins et al; Arch Int Med 2000

• Rathbun et al; Annals Int Medicine 2000

264 pts • Sens: 87% • Spec: 91%

STEIN et al. NEJM 2006

TEST SENS SPEC PPV NPV

CTA 83% 96% 86% 95%

CTA-CTV

90% 95% 85% 97%

Contrast Venography

• Gold Standard in Diag DVT • Accurate in Diagnosing or excluding in

99% of Cases

• Invasive, Technically difficult, Not Cost effective

VQ Scan

• Ventilation Phase: Pt inhales Xenon or Technetium through mouthpiece or face mask

• Perfussion Phase: Injection of Technetium labeled Macroaggregated albumin

• Both Images captured by Gamma Camera

VQ Scan

V/Q Scan

PIOPED STUDY: JAMA 1990

VQ scan

• A high clinical Probaility and High Probability VQ scan = usefull

• A Low clinical Probability and Normal or Low Probability VQ scan = usefull

Pregnancy and Radiation • Pregnancy: Radiation Exposure of less than 5 • rad considered safe

• CXR = < 1 millirad (mrad) • > 50 rad assoc with congenital malformation and leukemia 1:1000

• VQ scan Total Radiation Exposure = 1-20 mrad

• Ct Angio Radiation Exposure = 30 mrad

*VQ scan ?? test of Choice in Pregnancy as it has decreased

Maternal Radiation but higher Fetal Radiation*

Echocardiographic Findings in 105 Patients with Acute Pulmonary Embolism: Kasper et al.

• Dilatation of right pulmonary artery = 77 • Dilated right ventricle = 75 • E/F slope of mitral valve = 50 • Left ventricular dimension = 42 • Abnormal IV septal motion = 40 • Embolus in right pulmonary artery = 10 • Thrombi in right atrium or right ventricle = 4 • Normal echocardiogram = 19

Treatment

• 1993; Raschke et al NEJM: wt based heparin protocol

• 2000 Arch Int Medicine: Meta-analysis of UFH –vrs- LMWH = no difference

• Fondaparinux = Lovenox

Medical Treatment

IV unfractionated heparin

SC unfractionated heparin

LMWH

VKA

Fondaparinux

Rivaroxaban

Rivaroxaban (Xarelto)

• Oral factor Xa inhibitor

• Fixed dose (15mg BID x 3 wks then 20mg qd)

• No Monitoring

• 1 study showed no difference from Coumadin in bleeding or recurrence of DVT or PE

• Contraindicated if GFR < 30

Treatment

• Provoked VTE – 3m

• Unprovoked Distal DVT – 3m (re-eval)

• Unprovoked PE, Prox DVT – Indefinite

• 2nd unprovoked VTE – Indefinate

• Cancer Assoc – LMWH, Lifelong Tx

Case

• 52 yo M with PMH of Prostate CA and Resection 2 weeks ago presents with acute onset SOB and near Syncope.

• BP 90/40, P 140, 92% on 4L NC, RR 28 • Awake, Talking

The Next Best Step Would Be?

• A. ICU Admit, IVF, 02, Heparin gtt • B. ICU Admit IVF, 02, TPA • C. ICU Admit, IVF, 02 and ½ dose TPA

and Lovenox • D. ICU Admit, IVF, 02, Thrombectomy

The Next Best Step Would Be?

• B. ICU Admit IVF, 02, TPA

Diagnosis and Treatment Of PE Objectives

1. Pretest Probability for DVT/PE (Wells Criteria, Geneva Score)

2. D-Dimer, when is it appropriate and how to Interpret 3. Specificity and Sensitive US Doppler LE Venogram VQ Scan CT Angiogram 4. Indications for Thrombolytic Therapy 5. Indications for IVC filter

Consider TPA when…. Persistent hypotension

(SBP <90 mmHg or a drop in systolic blood pressure of ≥40 mmHg from baseline )

-------------------------------------------------------------------------------

No Strong Evidence For Following |

• Severe hypoxemia • Large perfusion defect on ventilation-perfusion scans

• Extensive embolic burden on computed tomography (CT) • Right ventricular dysfunction

• Free-floating right atrial or ventricular thrombus • Patent foramen ovale

Contraindications for TPA • Absolute - History of hemorrhagic CVA - Active Brain Neoplasm - Intracranial surg in past 2m - Active internal bleeding - Recent internal bleeding in past 6m

• Relative - Bleeding Diathesis - Uncontrolled HTN (SBP > 200) - non Hemorrhagic CVA in past 2m

- Surg within past 10d - Platelet count < 100K

ACCP guidelines: PE • Thrombolytics - TPA 100mg x 2hrs - Urokinase 4400IU loading dose + 2200IU x 12hr - Streptokinas 250,000 IU loading + 100,000 IU x 24hr - No heparin while lytics running - Risk of intracranial bleeding = 1-2% - No improvement in short or long term mortality (based on 9 studies) - Does improve radiographic and hemodynamic parameters (after 1 week no difference bw TPA vs Heparin gtt)

Catheter Directed ThrombolyticsThrTh

- Indicated When Pt has Higher Risk of Bleeding

- Center Has expertise in Modality - Pt is hemodynamically unstable and

Needs Lytics given Faster

ACCP Guidelines: PE

• Suction Extraction for pt’s unable to receive lytics

• Pulmonary Embolectomy - massive PE - hemodynamic instability - failed lytics - contraind to lytics

MOPETT TRIAL ACC March 2012

- 121 pts with hemodynamic stability - ½ Dose TPA 50mg + reduced Dose

Lovenox

- Reduced incid of pulm htn

Phlegmasia Cerulea Dolens Arterial & Venous Insuff

Thrombolytics For DVT

Phlegmacia Alba Dolens

Diagnosis and Treatment Of PE Objectives

1. Pretest Probability for DVT/PE (Wells Criteria, Geneva Score)

2. D-Dimer, when is it appropriate and how to Interpret 3. Specificity and Sensitive US Doppler LE Venogram VQ Scan CT Angiogram 4. Indications for Thrombolytic Therapy 5. Indications for IVC filter

IVC Filter

IVC Filter

• Contraindication or Complication to anticoagulation

• Recurrent VTE despite anticoag

IVC Filter • Short Term IVC filter reduces risk of PE • Long term > 2 years…IVC filter Assoc with

Increased rate of DVT

• IVC Filter has no role as stand alone therapy unless Anticoag contraindicated

• Retrievable IVC filters (removed after 2m) may be most practical approach

IVC Filter Complications

• Insertion Site Hematoma • DVT at Insertion Site • Filter Migrations • Filter errosion • Filter embolization • IVC thrombosis

Summary • A low Probability clinical score and Negative D Dimer exclude PE

• A negative LE USS excludes DVT but in high probability PE patients it adds

little

• A CT angio (spiral/Helical) is test of choice for PE

• A VQ scan is test of choice in pregnancy in stable pts

• Thrombolytics have only 1 STRONG indication = hypotension from PE. It does not improve mortality

• IVC filters should onlt be used if there is a contraind to Anticoag or failed developed a clot while therapeutic on anticoag

• IVC filters prevent PE short and long term, but increases DVT rates long term