ISSUES IN TREATMENT OF ACUTE PULMONARY THROMBOEMBOLISM

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

38. 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

39. 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)”

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

41. DIAGNOSIS : MASSIVE PTE

42. 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

43. THROMBOLYTIC TREATMENT IS CONTRAINDICATED ?

44. 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

45. 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)

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

47. NO CONTRAINDICATION FOR THROMBOLYTIC TREATMENT

48. 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

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

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