Pulmonary embolism
!! The 3rd most common cardiovascular disease !!!
According to autopsy only 30% correctly recognized
while
Mortality of recognized and treated PE is 8%
non-recognized and not treated 30%
40-50% patients with DVT have asymptomatic PE
!! Always consider possibility of PE !!
Definition
Obstruction of part of pulmonary arterial system by
• trombus
• fat
• air
• amniotic fluid
Source
• leg deep vein thrombosis (85%)
• pelvic vein
• renal vein
• vena cava inferior
• right heart
• importance of vena cava sup. is increasing
( central vein catheter, ICD, PM,….)
Risk factors - Virchow trias
Risk factors
• Congenital
• Acquired
• Predisposing
• Triggers
Congenital thrombofile RF
• APC resistance - FV Leiden (homozyg.)
• def. AT III, prot. C, prot. S, Fbg.
• Von Willebrand (def. f VIII)
• MTHFR
• PT20210a
• fibrinolysis disorders
Acquired thrombofile RF
• immobilisation
• surgery
• Malignancy
• myeloproliferation
• hormone th., drugs (tamoxifen, leflunomid..)
• chronic heart failure, lung disease
• autoimmune dis.
• infections
Predisposing RF
• age
• obesity
• varices
• history of thrombosis/VTE
• anatomic abnormalities (May-Thurner, Paget-Schroetter)
Triggers
➢ travelling
➢ trauma
➢ venous catheters
➢ pregnancy
➢ e-thrombosis…
Pathophysiologic concequences
Extent
localization
status of cardiopulmonary system
Hemodynamically significant PE causes acute pulmonary
hypertension → pressure elevation in right sided heart
compartments → dilatation, acute Tri insuf → acute right
heart failure, in case of massive PE also decrease of minute
volume → systemic hypotension.
Irritation of „stretch“ receptors → hyperventilation →
hypoxemia a hypocapnia
Symptomes of PE
acute X subacute (successive)
high-risk (shock, ↓TK) vs. not high-risk
Sudden death - cca 10%
Dyspnea at rest - almost in 95 % - abrupt onset, abruptly
worsened
Chest pain - cca 50%, of any type
Hemoptysis - only in case of pulmonary infarction - cca 15%
Cought, syncope
Clinical - tachypnea and tachycardia
acute right heart failure
hypotension
cardiogenic shock
Investigations
• ECG
• X-ray (not specific)
• ECHO
• pulmonary arteriography
• spiral CT angiography
• pulmonary scintigraphy
• blood sample
• duplex sono of leg veins – exclusion of thrombosis
ECG
• S I
• Q III
• Neg.T v III, V1 – V4
• Tachycardia
• RBBB
• Right axis deviation
• P pulmonale in II, III
RV hypertrophy is not typical for PE
ECG
ECHO
• akinesia of the mid-free wall but normal motion of
the apex
• RV dilatation
• D shape of left ventricular cavity during
contraction
• doppler measurement of pulmonary flow
• tricuspidal regurgitation
ECHO
Laborathory
• DDimers
- breakdown products of a blood clot
- negative ELISA test excludes TE process
- falsely positiv – infection, pregnancy, injury,
recent surgery
• BNP
• TropT
• Astrup – hypoxemia, hypocapnia
CT AG
• CT pulmonary angiography
• high senzitivity and specificity
• limitations: allergy
induced postcontrast nephrophaty
small peripheral arteries
pregnant patients (better than SPECT)
CT AG
SPECT
• high sensitivity, low specificity → negative scan
excludes PE
• combined ventilation-perfusion scan, in comparison
with chest X-ray, integration with orientation CT
SPECT
Therapy of PE
Opening of ocluded pulmonary arteries
• Thrombolysis can be started up to 14 days since PE
– indication criteria: hypotension, cardiog. shock
- symptomes of right heart faulire
- unsuccesful heparin therapy, increasing or recidivous
KI – high risk of fatal bleeding
• Anticoagulation - full anticoag. dose
- UFH or LMWH
- fondaparinux
- warfarin
- NOAC (dabigatran, rivaroxaban, apixaban, edoxaban)
• Embolectomy – only several dept. all over the world
• Catheter therapy
Prevention of TED (TEN)
Risk stratification before surgery
Physical prevention - early mobilization, venous
gymnastic (dorsal and plantar ankle flexion), elastic
stockings, bandages
Pharmacologic prevention - LMWH, fondaparinux
Caval filter