ACUTE PULMONARY EMBOLISM Part I
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Transcript of ACUTE PULMONARY EMBOLISM Part I
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ACUTE PULMONARY EMBOLISMPart I
Etiology,Clinical features,DiagnosisDr Vinod G V
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• PE and DVT are two clinical presentations of venous thromboembolism (VTE) and share the same predisposing factors.
• Most cases of PE occurs as a consequence of DVT
• Acute case fatality rate for PE ranges from 7 to 11%
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N=94194; 6 yr follow up.The incidence rate for • All first VT events was 1.43 per 1000 person-years [95% confidence
interval (CI): 1.33–1.54]
• Deep-vein thrombosis (DVT) was 0.93 per 1000 person-years (95% CI: 0.85–1.02)
• Pulmonary embolism (PE) was 0.50 per 1000 person-years (95%CI:
0.44–0.56).
J Thromb Haemost 2007; 5: 692–9.
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Acquired factors
• Reduced mobility• Advanced age• Cancer• Acute medical illness• Major surgery• Trauma• Spinal cord injury• Pregnancy and
postpartum period
• Polycythemia vera• Antiphospholipid antibody
syndrome• Oral contraceptives• Hormone-replacement
therapy• Heparins• Chemotherapy• Obesity• Central venous catheterization• Immobilizer or cast
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Hypercoagulable states • Factor V Leiden resulting in activated protein C resistance• Prothrombin gene mutation • Antithrombin deficiency• Protein C deficiency• Protein S deficiency
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• First thrombosis usually at young age (<40 yr)• Frequent recurrences• Family history of VTE
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Pathophysiology
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Clinical featuresSymptoms• unexplained dyspnea• Chest pain, either pleuritic
or “atypical”• Cough• Haemoptysis
Signs• Tachypnea• Tachycardia• Low-grade fever• Left parasternal lift• Tricuspid regurgitant murmur• Accentuated P2• Hypotension
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Clinical classificationMassive PE: • Systolic blood pressure <90 mm Hg • Poor tissue perfusion or • Multisystem organ failure plus • Right or left main pulmonary artery thrombus or “high clot burden”
Submassive PE:• Hemodynamically stable but moderate or severe right ventricular
dysfunction or enlargement
Small to moderate PE: • Normal hemodynamics and normal right ventricular size and function
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Classic Well’s criteria SCORE POINTS • DVT symptoms or signs -3 • An alternative diagnosis is less likely than PE -3 • Heart rate >100/min -1.5 • Immobilization or surgery within 4 weeks -1.5 • Prior DVT or PE -1.5 • Hemoptysis -1 • Cancer treated within 6 months or metastatic -1 >4 score points = high probability ≤4 score points = non–high probability
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ECG
• Sinus tachycardia• Incomplete or complete right bundle branch block• Right-axis deviation• T wave inversions in leads III and aVF or in leads
V1-V4• S wave in lead I and a Q wave and T wave
inversion in lead III (S1Q3T3) • Atrial fibrillation or atrial flutter
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CHEST X RAY• Major chest radiographic abnormalities are uncommon.
• A near-normal radiograph in the setting of severe respiratory compromise is highly suggestive of massive PE.
• Focal oligemia (Westermark sign) indicates massive central embolic occlusion.
• A peripheral wedge-shaped density above the diaphragm (Hampton hump) usually indicates pulmonary infarction.
• Enlargement of the descending right pulmonary artery. The vessel often tapers rapidly after the enlarged portion
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ECHO• Right ventricular enlargement or hypokinesis, especially free wall
hypokinesis, with sparing of the apex (the McConnell sign) • Interventricular septal flattening and paradoxical motion toward the left
ventricle, resulting in a D-shaped left ventricle in cross section• Tricuspid regurgitation• Pulmonary hypertension with a tricuspid regurgitant jet velocity >2.6
m/sec• Loss of respiratory-phasic collapse of the inferior vena cava with
inspiration• Dilated inferior vena cava without physiologic inspiratory collapse• Direct visualization of thrombus (more likely with transesophageal
echocardiography)
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Computed Tomography
• Most commom investigation performed• SDCT or MDCT • MDCT more sensitive for subsegmental level
thrombi• CT can rule out other causes
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CT
• Two clinical studies reported a sensitivity around 70% and a specificity of 90% for single-detector CT (SDCT).
• Negative SDCT and the absence of a proximal DVT on lower limb venous ultrasonography in non- high clinical probability patients was associated with a 3-month thromboembolic risk of approximately 1%
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• For MDCT a sensitivity of 83% and a specificity of 96% .• In patients with a low or intermediate clinical
probability of PE as assessed by the Wells score, a negative CT had a high NPV for PE (96 and 89%respectively) and only 60% in those with a high pretest probability.
• The PPV of a positive CT was high (92–96%) in patients with an intermediate or high clinical probability but
much lower (58%) in patients with a low pretest likelihood of PE
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D-Dimer Assay
• Endogenous fibrinolysis• More sensitive but less specific• Negative predictive value• Not very useful in hospitalized patients since
values may be elevated due to comorbid illness
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• D-dimer ELISA is an excellent screening test for suspected PE
• A negative D-Dimer assay in low clinical probability case rules out PE
• D-dimer ELISA was often elevated in the absence of PE like sepsis,cancer,acute medical illness
• Low specificity and poor positive predictive value
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Trop I
• Elevated levels indicates RV dialatation or RV dysfunction
• Helps to identify patients with massive pulmonary embolism
• Has prognostic value
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Pulmonary Angiography
• Invasive procedure• Considered previously as gold standard • Now rarely performed as a diagnostic
procedure• Direct evidence of thrombus seen as filling
defect or amputation of an arterial branch.
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Lung V/Q Scan
• Not performed routinely• In patients with elevated D Dimer and
contraindication for CT contrast allergy;renal failure
• Shows multiple perfusion defects in massive pulmonary embolism
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Venous Ultrasonography
• Evidence of DVT in lower limbs• Loss of vein compressibility• 50% of patients with PE has no evidence of
DVT
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SUMMARY
• High clinical suspicion is needed for diagnosis• No symptoms , signs or test is highly specific
for PE• Assess pretest clinical probability before
applying diagnostic test• Integrated diagnostic approach is needed
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.Most common cause of inherited thrombophiliaA.Factor V LeidenB.Prothrombin gene mutationC.protein c defficiencyD.protein s defficiency
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2. Most common ECG finding seen in patients with acue pulmonary embolismA.Sinus tachycardiaB.S1Q3T3C.T inversion in precordial leadsD.RBBB
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Well’s score includes all exceptA.Cancer treated within 6 months B.HaemoptysisC.Surgery within 4 wksD.Dyspnoea
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D Dimer assay in acute pulmonary embolism ;wrong statementA.specificity is low B.High NPV in low probability casesC.Values >500ng/ml diagnostic of PED.Most useful in emergency department than in hospitalised patients
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Most common symptom in PEA.Pleuritic chest painB.HaemoptysisC.Sudden onset dyspnoeaD.Syncope
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Most common clinical sign in PEA.TachypnoeaB.RV S3C.Elevated JVPD.Pleural rub
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False statement about ECHO IN PEA.Mc connell’s sign most sensitive signB.RV dilatation indicates poor prognosisC.D shaped LV D.TEE more sensitve for demonstrating
thrombus