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Adam Mora, Jr., MD, FCCP

Chairman – Pulmonary & Critical Care Symposium

Intensivist - Baylor University Medical Center

Course Director- Critical Care Medicine

Assistant Professor-

Texas A&M Health Science Center College of Medicine

Medical Director/Chief of Staff-

Select Specialty Hospital Dallas – Downtown

Select Specialty Hospital Dallas - Garland

PULMONARY EMBOLISM

DISCLOSURES

• None related to this topic

OBJECTIVES:

• Discuss incidence and possible theories for rising incidence

• Discuss Morbidity and Mortality of PE in the US

• Discuss the entity of “Post-PE Syndrome”

• Review European classification system and its contrast to US classification

• Treatment approach based on European Classification System

• Describe intravascular lytic therapy – risks and benefits

• Describe intravascular mechanical extraction, risks and patient candidacy

OBJECTIVES:

• Discuss incidence and possible theories for rising incidence

• Discuss Morbidity and Mortality of PE in the US

• Discuss the entity of “Post-PE Syndrome”

• Review European classification system and its contrast to US classification

• Treatment approach based on European Classification System

• Describe intravascular lytic therapy – risks and benefits

• Describe intravascular mechanical extraction, risks and patient candidacy

Date of download: 3/2/2017Copyright © 2017 American Medical

Association. All rights reserved.

From: Trends in the Incidence of Deep Vein Thrombosis and Pulmonary Embolism A 25-Year Population-Based Study

Arch Intern Med. 1998;158(6):585-593. doi:10.1001/archinte.158.6.585

Annual incidence of all venous thromboembolism, deep vein thrombosis (DVT) alone, and pulmonary embolism (PE) with or withoutdeep vein thrombosis (PE ± DVT) among residents of Olmsted County, Minnesota, from 1966 to 1990, by age.

Figure Legend:

THE INCIDENCE OF PULMONARY EMBOLISM IS HAS INCREASED DUE TO THE FOLLOWING?

• A. Increase in new risk factors not previously associated with PE risk

• B. Improved detection techniques and awareness of PE

• C. Improved statistics for tracking DVT/PE

• D. There is a sharp decline in incidence

• E. There is no incidence increase

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THE INCIDENCE OF PULMONARY EMBOLISM IS HAS INCREASED DUE TO THE FOLLOWING?

• A. Increase in new risk factors not previously associated with PE risk

• B. Improved detection techniques and awareness of PE

• C. Improved statistics for tracking DVT/PE

• D. There is a sharp decline in incidence

• E. There is no incidence increase

IMPROVED DETECTION

BMJ.com

Figure 1. Timeline of recent public health activities and initiatives related to venous thromboembolismAHRQ, Agency for Healthcare Research and Quality; APHA, American Public Health Association; ASH, American Society of Hematology; CMS, Centers for Medicare an...

Michele G. Beckman, W. Craig Hooper, Sara E. Critchley, Thomas L. Ortel

Venous Thromboembolism: A Public Health Concern

American Journal of Preventive Medicine, Volume 38, Issue 4, Supplement, 2010, S495–S501

http://dx.doi.org/10.1016/j.amepre.2009.12.017

RISKS• Men = Woman

• Age

• For every 10 years after age 60, risk doubles

• DVT

• Bedridden

• Surgery

• Chronic heart disease / HTN / Lung disease / IBD (Crohn’s and UC)

• Genetics

• 5 - 8% of the U.S. population has one of several genetic risk factors

• Inherited thrombophilias

• Smoking

• Pregnancy and up to 6 weeks post partum

• Central venous catheters

• Obesity

• Hormone therapy

• Cancer

NIH 2007 www.nglbi.nih.gov – “Who is at risk for Pulmonary Embolism”

MORBIDITY AND MORTALITY

• Over 600,000 Americans affected each year1

• ONE PER MINUTE

• Precise number of people affected by DVT/PE is unknown

• As many as 900,000 people could be affected

• 1 to 2 per 1,000 / year in US

• Cause more deaths than breast cancer and AIDS combined1

• 10 - 30% die within 1 month of diagnosis

• Sudden death is the first symptom in ~25% of people who have a PE

• Leading cause of preventable hospital deaths in the US2

• Leading cause of maternal death in the US3

• One-half of patients will have long-term complications4

• One-third will have a recurrence within 10 years4

• An estimated $10 billion in medical costs in the US each year can be attributed to DVT and PE5

1 Nabel, Elizabeth MD (Director, NIH’s National Heart, Lung, and Blood Institute) in the Surgeon General’s Call to Action to PreventDeep Vein Thrombosis and Pulmonary Embolism US Department of Health and Human Services 2008 p. 5. 2 Baglin TP, White K, Charles A. Fatal pulmonary embolism in hospitalized medical patients. J Clin Pathol 1997;50(7):609-10 3 Berg CJ, Atrash HK, Koonin LM, Tucker M. “Pregnancy-related mortality in the United States 1987-1990”. Obstet Gynecol 1996;88(2):161-7 Also see Marik. P.E. and Plante, L.A. “Venous Thromboembolic Disease and Pregnancy”. New England Journal of Medicine, volume 359, number 19, November 6, 2008, pages 2025-2033. 4 Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern.Am J Prev Med. 2010 Apr;38(4 Suppl):S495-501. 5 Gross, Scott. CDC “Incidence based cost-estimates require population based incidence data” 2012 http://www.cdc.gov/ncbddd/Grosse/cost-grosse-Thrombosis.pdf

WHICH OF THE FOLLOWING IS TRUE FOLLOWING A PULMONARY EMBOLISM?

• A. One can expect complete resolution of symptoms once anticoagulation is complete.

• B. Only chronic thromboembolic disease patients with pulmonary hypertension have persistent symptoms following a PE.

• C. The pathophysiological changes of pulmonary arteries post PE are well understood.

• D. The quality of life can be decreased after acute PE compared to population controls.

• E. A pulmonary embolism will not affect mental status.

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WHICH OF THE FOLLOWING IS TRUE FOLLOWING A PULMONARY EMBOLISM?

• A. One can expect complete resolution of symptoms once anticoagulation is complete.

• B. Only chronic thromboembolic disease patients with pulmonary hypertension have persistent symptoms following a PE.

• C. The pathophysiological changes of pulmonary arteries post PE are well understood.

• D. The quality of life can be decreased after acute PE compared to population controls.

• E. A pulmonary embolism will not affect mental status.

POST-PE SYNDROME

POST-PE SYNDROMEQUALITY OF LIFE

• Several studies have consistently reported a decreased QoL after acute PE compared to population controls

• In a population of 392 patients 3.5 years after PE diagnosis, patients had substantially lower QoL than population norms on all subscales

• Study in 109 consecutive patients in an outpatient clinic two years after PE diagnosis confirmed the worse scores measured by the SF-36 in PE patients as compared to the general Dutch population

• Lower QoL in patients after acute PE vs. DVT alone

• especially on the subscales physical quality of life and mental fatigue

1. Klok FA, van Kralingen KW, van Dijk AP, et al. Quality of life in long-termsurvivors of acute pulmonary embolism. Chest 2010;138:1432–40.2. Stevinson BG, Hernandez-Nino J, Rose G, Kline JA. Echocardiographic and functional cardiopulmonary problems 6 months after first-time pulmonary embolism in previously healthy patients. Eur Heart J 2007;28:2517–24.3. van Es J, den Exter PL, Kaptein AA, et al. Quality of life after pulmonary embolism as assessed with SF-36 and PEmb-QoL. Thromb Res 2013;132:500–5.4. Hogg K, KimptonM, CarrierM, Coyle D, Forgie M, Wells P. Estimating quality of life in acute venous thrombosis. JAMA Int Med 2013;173:1067–72.5. Klok FA, Cohn DM, Middeldorp S, et al. Quality of life after pulmonary embolism: validation of the PEmb-QoL Questionnaire. J Thromb Haemost 2010;8:523–32.6. Abstracts of the XXIV Congress of the International Society on Thrombosis and Haemostasis. June 29-July 4, 2013. Amsterdam, The Netherlands. Abstract number PA 3.06–2. J Thromb Haemost 2013;11(Suppl. 2):1–1322.7. Lukas PS, Krummenacher R, Biasiutti FD, Begré S, Znoj H, von

THE POST-PE SYNDROME AFTER ACUTE PE

• CTEPH seems to be the extreme (and perhaps ultimate) manifestation of a much more common phenomenon of abnormalities

• pulmonary artery flow

• pulmonary ventilation

• cardiac function after

• Underlying pathophysiology is not as clearly described or understood

CHRONIC CONSEQUENCES 2 YRS POST PE

PROPOSED PATHOPHYSIOLOGICAL CASCADE OF THE POST-PE SYNDROME