28/10/2014 Objectives • Guidance Acute Pulmonary Embolism • Accurate diagnosis • Risk stratification • Treatment – Thrombolysis Will not be addressing CTEPH Mean age of presentation Pulmonary embolism • PE estimated 100 per 100,000 per year 1 – Third most common cardiovascular disorder in industrialised countries 2 • Wide variety of presentations – Incidental discovery to cardiogenic shock • Mortality high as 25% – untreated • Incidence rises with age 1 Cohen et al Thromb Haemost 2007;98:756-64. 2 Douma et al Nat Rev Cardio 2010 Pulmonary embolism • PE and DVT – DVT; 50% asymptomatic PE – PE; 70% have DVT 1 – Mortality dictated by presenting feature 1 • Provoked vs unprovoked – 10-20% unprovoked – Surgery/cancer/heart failure/obesity etc Adapted from Douma et al Nat Rev Cardio 2010 Mortality in pulmonary embolism • >90% of deaths from missed diagnosis 1 • Up to 10% present with shock 2 • 50% with signs of right ventricle compromise – CTPA, ECHO • Distraction of imaging – Mortality not dictated by clot burden • Presence of haemodynamic stability key marker • 1-4% go on to develop CTEPH 1 ESCARDIO European Heart Journal (2008) 29, 2276–2315 1 2 Pengo et al N Engl J Med 2004;350:2257–2264 ESCARDIO European Heart Journal (2008) 29, 2276–2315 1 28/10/2014 Mortality from PE Current guidelines • NICE Guideline for Venous Thromboembolic Diseases (2012) – Short on detail – Useful introduction • 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism – More detailed guidance – International board of experts a; in the presence of shock it is not necessary to confirm RV dysfunction or myocardial damage ESCARDIO European Heart Journal (2008) 29, 2276–2315 Case presentation • 60 year old man, recent discharge • Pneumonia, para-pneumonic effusion with slow recovery • Attended c/o limb pain. – US performed – no DVT seen – Mild pleuritic pain – felt related to recent infection • Discharged for follow up at planned OPC appt Case presentation • Re-presented with worsening SOB • Septic, fever, inflammatory markers elevated – New since presentation with limb pain • • • • CXR appearances slightly worse Now hypoxaemic Treated for infection No hypotension 2 28/10/2014 Wells Score Wells Rule Original Version (2000) Wells Score Simplified version (2007) Wells Rule Original Version (2000) Simplified version (2007) Previous PE or DVT 1.5 1 Previous PE or DVT 1.5 1 HR ≥ 100 bpm 1.5 1 HR ≥ 100 bpm 1.5 1 Surgery or immobilisation within the past four weeks 1.5 1 Surgery or immobilisation within the past four weeks 1.5 1 Haemoptysis 1 1 Haemoptysis 1 1 Active cancer 1 1 Active cancer 1 1 Clinical signs of DVT 3 1 Clinical signs of DVT 3 1 Alternative diagnosis is less likely than PE 3 1 Alternative diagnosis is less likely than PE 3 1 Clinical Probability Clinical Probability Two-level score Two-level score PE unlikely 0-4 0-1 PE unlikely 0-4 0-1 PE likely ≥5 ≥2 PE likely ≥5 ≥2 Clinical course • • • • • • Treated with high flow oxygen Intravenous antibiotics LMWH and then rivaroxaban Weaned oxygen within the next 10 days Discharged with OPC follow up Making good progress Diagnosis of PTE • Clinical risk assessment – Clinical judgement • • • • History and clinical examination CXR ECG D-dimer – Risk score • Diagnostic algorithm 3 28/10/2014 Prevalence of PE in clinically suspected cases Low risk PE Pulmonary embolism (%) 60 50 40 30 20 10 0 1980 1988 1996 1998 2005 Year High risk PE Investigations • CXR – Westermark’s sign – Rare and almost never seen – RV dilatation • D Dimer • Leg doppler vs V/Q vs CTPA – PC dictates prognosis • Bedside echocardiography • Additional tests – Troponin Prognosis and D DImer D-dimer: specific patient populations 553 patients Negative D-dimer 266 No further imaging 229 Further imaging 37 (14%) VTE, 2 Positive D-dimer 287 No further imaging 137 (48%) Further imaging 150 VTE, 20 Outpatients Patients < 60 years Patients > 80 years Inpatients Cancer patients Previous DVT or PE Pregnancy Before 30th week Weeks 31 to 42 Number needed to test 3 2 20 14 9 6 2.6 4 Ann Emerg Med. 2009;54:442-446. 4 28/10/2014 MDCT: summary of outcome studies CT and cancer risk 3-month thromboembolic risk in patients left untreated based on a negative MDCT scan: CTEP3 study (n=756) 1.7% (0.7 to 3.9) CHRISTOPHER study (n=3306) 1.3% (0.7 to 2.2) PEDS study (n=694) 0.4% (0.1 to 1.3) CTEP4 study (n=1693) 0.3% (0.1 to 1.1) Radiation dose: CT 9 to 20 mSv V/Q 1.1 mSv Lifetime attributable risk of a single CT 20-year old female 80-year old male A negative CT safely rules out PE in patients with a low to intermediate clinical probability N Engl J Med 2005;352:1760-8. JAMA 2006;295:172-9; JAMA 2007; Lancet 2008;371:1343-52 Prognostic assessment • Acute RV dysfunction is a critical determinant – Systemic hypotension – Cardiogenic shock – Syncope • Troponin – Marker of myocardial injury – Higher mortality in both unstable and stable patients 0.8% 0.05% Einstein et al. JAMA 2007;298:317-323 What defines haemodynamic instability? • PIETHO study – Need for cardiopulmonary resuscitation Or – Systolic BP < 90mmHg for >=15 min or drop by >=40mmHg for >=15 mmHg with end organ hypoperfusion Or – Need for inotropic support to maintain adequate organ perfusion and a systolic BP of >90 mmHg Key factors contributing to haemodynamic collapse in acute PE Treatment 5 28/10/2014 Low risk Low risk • LMWH • Fondaparinux • Rivaroxaban • UFH PTE Intermediate risk High risk Intermediate risk Normal resuscitation measures IVI should be started without delay • LMWH • Fondaparinux • UFH • ?Thrombolysis High risk Normal resuscitation measures IVI should be started without delay • Thrombolysis • Embolectomy • Catheter fragmentation • UFH • LMWH • Fondaparinux Summary • Diagnosis of PE has and will continue to be challenging • Appropriate clinical assessment, risk stratification and investigations correctly identify those patients whom may benefit from therapy 6
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