ISSUES IN TREATMENT OF ACUTE PULMONARY THROMBOEMBOLISM - PowerPoint PPT Presentation

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ISSUES IN TREATMENT OF ACUTE PULMONARY THROMBOEMBOLISM

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ISSUES IN TREATMENT OF ACUTE PULMONARY THROMBOEMBOLISM

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  1. ISSUES IN TREATMENT OF ACUTE PULMONARY THROMBOEMBOLISM Asc.Prof. SERHAT FINDIK, MD FCCP Ondokuz Mayis University Faculty of Medicine Department of Pulmonary Medicine

  2. ACUTE PULMONARY THROMBOEMBOLISM • One of the most common causes of death • Mortality without treatment : 30% • Most of the deaths within first hours • Mortality with treatment : 2 – 8 %

  3. ACUTE PULMONARY THROMBOEMBOLISM • Variable clinic picture asymptomatic – severe hipoxemia, right ventricular failure, shock, death • Treatment depends on clinical picture of the patient

  4. PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment

  5. ANTICOAGULATION IS CONTRAINDICATED ?

  6. ABSOLUTE CONTRAINDICATIONS ACTIVE MAJOR HEMORRHAGE • Intracranial hemorrhage • Retroperitoneal hemorrhage • Intrathoracic hemorrhage (lungs- pleura) • Hemorrhages causing > 2 gr / dL in hemoglobin

  7. RELATIVE CONTRAINDICATIONS • Recent surgery (within two weeks) • Recent trauma (within two weeks) • Bleeding diathesis • Uncontrolled severe hypertension (systolic blood pressure > 200 mmHg, diastolic >120 mmHg) • Peptic ulcer

  8. WELLS İNDEX POINT • Age > 65 1 • History of gastrointestinal bleeding 1 • Stroke 1 • At least one of the below ; 1 Hematocritet < %30 Creatinine > 1.5 mg/dl Diabetes mellitus Recent acute myocard infarction • Evaluation Low risk : 0 point, Moderate risk : 1 – 2 points High risk : ≥ 3 points

  9. CONTRAINDICATION FOR ANTICOAGULATION

  10. PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment

  11. DIAGNOSTIC EVALUATION • DIAGNOSIS : PULMONARY THROMBOEMBOLISM • CONTRAINDICATION FOR ANTICOAGULATION

  12. INFERİOR VENA CAVA FİLTER

  13. INDICATIONS • Contraindication for anticoagulation • Recurrent PTE despite anticoagulation • Major hemorrhage as a side effect of anticoagulation • Severe compromisement of pulmonary vascular bed such as massive PTE, CTEPH.

  14. ANTICOAGULATION IS NOT CONTRAINDICATED

  15. PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment

  16. ANTICOAGULANT MUST BE GİVEN ? • Give in a patient with a high clinical risk for PTE • Mortalite without treatment is 30% • Risk for major hemorrhage is 3% • Patients with low – moderate clinical risk for PTE ? • Effectiveness of treatment depends on its effect within 24 hours

  17. PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment

  18. DIAGNOSTIC EVALUATION • DIAGNOSIS : PULMONARY THROMBOEMBOLISM

  19. PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment

  20. ACUTE PULMONARY THROMBOEMBOLISM • MASSIVE ? • SUBMASSIVE ?

  21. MASSIVE PTE ? • Hemodynamic evaluation • Physical examination • ECG • Spiral CT pulmonary angiography • ECHO • Troponin / BNP • Arterial blood gases

  22. HEMODYNAMIC EVALUATION • HYPOTENSION systolik blood pressure < 90 mmHg *, sudden decrease (at least 40 mmHg) in systolic blood pressure • TACHYCARDIA > 130 – 140 pulses / min • TACHYPNEA > 30 / min • SHOCK / COMA

  23. PHYSICAL EXAMINATION • SIGNS FOR COR PULMONALE Prominence of neck veins Orthopnea Tachypnea Systolic murmur on tricuspid area(“Carvello maneuvre”) Prominence of S2 on pulmonary area Cyanosis

  24. ELECTROCARDIOGRAPHY • Right ventricular strain pattern on anterior leads (V1-V4) • S1Q3T3 • Right bundle block • Right axis deviation • Tachycardia* • P pulmonale • Normal signs and / or nonspecific ST/T changes

  25. SPIRAL CT PULMONARY ANGIOGRAPHY • Emboli burden • Pulmonary hypertension • Right ventricular dysfunction • Leftward shift of interventricular septum • Thrombus within right atrium or right ventricule • Patent foramen ovale • Thrombus within inferior vena cava

  26. ECHOCARDIOGRAPHY • Dilatation of right ventricule • Leftward shift of interventricular septum • Decrease in ejection fraction (<%50) • Thrombus within right ventricule or right atrium • Pulmonary hypertension ( > 45-50 mmHg) • Patent foramen ovale

  27. TROPONINE / BNP • High BNP, early mortality • Elevation of troponine increase mortality • Troponine I > 0.5 ng/mL in submassive PTE : Mortality within three months increases 3.5 times • Heart-type fatty acid binding protein (H-FABP)”

  28. ARTERIAL BLOOD GASES • PaO2 < 60 mmHg • Sat O2 < %90 • Hypercapnia

  29. DIAGNOSIS : MASSIVE PTE

  30. PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment

  31. THROMBOLYTIC TREATMENT IS CONTRAINDICATED ?

  32. ABSOLUTE CONTRAINDICATIONS • Active major hemorrhage • History of hemorrhagic stroke • Active intracranial neoplasm • Recent (within two months) intracranial surgery or trauma • Active (or within past 6 months) internal organ bleeding

  33. RELATIVE CONTRAINDICATIONS • Bleeding diathesis • Uncontrolled severe hypertension (systolic blood pressure >200 mmHg, diastolic blood pressure > 120 mmHg) • History of nonhemorrhagic stroke within 2 months • Surgery within 10 days • Thrombocytopenia (100.000 / mm 3)

  34. ABSOLUTE CONTRAINDICATIONS ACTIVE MAJOR HEMORRHAGE • Intracranial hemorrhage • Retroperitoneal hemorrhage • Intrathoracic hemorrhage (lungs- pleura) • Hemorrhages causing > 2 gr / dL in hemoglobin

  35. NO CONTRAINDICATION FOR THROMBOLYTIC TREATMENT

  36. PTE ? Contraindication to anticoagulation Yes No Diagnostic evaluation sc LMWH or IV Heparin Diagnostic evaluation PTE - PTE + Other diseases Inferior vena cava filter PTE - PTE + Massive PTE ? Stop anticoagulation Yes No Contraindication to thrombolytic Yes Anticoagulation Embolectomy No Thrombolytic treatment

  37. THROMBOLYTIC DRUGS • STREPTOKINASE • UROKINASE • TISSUE TYPE PLASMINOGEN ACTIVATOR (TPA)

  38. THROMBOLYTIC DRUGS • Plasminogen → Plasmine • Direct lyzis of thrombus