Pulmonary Embolism: Current Concepts in Diagnosis and Management. Gregory Piazza, MD July 26, 2005. Objectives. To examine the state-of-the-art in the evaluation of patients with suspected pulmonary embolism (PE). To review the recent advances in risk stratification of patients with PE.
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Gregory Piazza, MD
July 26, 2005
Lancet 2004; 363:1295-1305
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How should this patient be worked up?
Dyspnea (most frequent symptom)
Pleuritic chest pain
Tachypnea (most frequent sign)
Elevated JVD (most specific sign)
Paradoxical bradycardiaThe History and Physical
Arterial blood gases Management
Lower extremity ultrasound
Ventilation-perfusion lung scanning
Spiral chest CT
Magnetic resonance (MR) angiography
Contrast pulmonary angiographyThe Diagnostic Armamentarium
“Everything you can do is not everything you should do.”
Common electrocardiographic findings:
- cardiomegaly (27%)
- normal (24%)
- pleural effusion (23%)
- elevated hemidiaphragm (20%)
- pulmonary artery enlargement (19%)
- atelectasis (18%)
- pulmonary infiltrate (17%)
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History and Physical Management
Eval. clinical likelihood
Patient in ED
Inpatient or high prob.
V/Q if dye allergy or renal insufficiency
Treat for PE
No PEAn Integrated Approach
Did we see this coming?
Risk Stratification Tools:
ICOPER reported several independent clinical predictors of increased mortality at 3 months.History and Physical
↑ PVR increased mortality at 3 months.
↑ RV pressure
↑ RV shear stress
↑ Natriuretic peptide mRNA
↑ BNPCardiac Biomarkers
No shock increased mortality at 3 months.
No RV dysfunction
Consider thrombolysis or embolectomyCardiac Biomarkers
Echocardiography is very sensitive in identifying RV dysfunction in PE.
RV dysfunction has proven to be one of the strongest predictors of adverse outcomes and recurrent PE.
Typical findings in PE include:
Moderate to severe RV free wall hypokinesis with apical sparing (McConnell Sign)
Paradoxical interventricular septal motion
Loss of respiratory-phasic changes in IVC
Decrease in the difference between LV area during diastole and systole (marker of cardiogenic shock)Echocardiography
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How should we manage this patient?
Primary therapy: dysfunction in PE.
Open surgical embolectomy
IV unfractionated heparin
Low-molecular weight heparin (LMWH)
IVC filterPrimary v. Secondary Therapy
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Cumulative risk of recurrent venous thromboembolism dysfunction in PE.Duration of Anticoagulation: PREVENT
N Engl J Med 2003;348:1425-34
Cumulative probability of recurrent venous thromboembolism dysfunction in PE.Duration of Anticoagulation: ELATE
N Engl J Med 2003;349:632-9
Not High Risk
Consider 1˚ Therapy
Warfarin for 6 months
If idiopathic PE, continue anticoagulation indefinitely
Stop if PE was caused by surgery or trauma
Bauer K. Pentasaccharides. October 16, 2003.
Indicated to reduce the incidence of PE in: dysfunction in PE.
PE or recurrent PE despite adequate anticoagulation
Patients with contraindications to anticoagulation
Open surgical pulmonary embolectomy
Do not address the thrombotic process
Peripheral leg edema can ensue
Large venous collaterals can develop and permit PE
Filters may be deployed improperly or have technical problems
Increased incidence of DVT (at 2 years, 21% v. 12%, p=0.02)
No survival benefitInferior Vena Cava (IVC) Filters
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