Escolar Documentos
Profissional Documentos
Cultura Documentos
Pekerjaan :
Staf Divisi Hematologi Onkologi Medik Dept.
IPD FKUI/RSCM
ARTERIAL - VENOUS THROMBO EMBOLY:
PERIPHERAL ARTERIOVASCULAR DISEASE
& PULMONARY EMBOLY
Coronary artery
Plaque rupture
unstable angina Pulmonary embolism
Myocardial infarction
(MI) / heart attack
(PE)
Deep vein
thrombosis (DVT)
PAD
PATHOPHYSIOLOGY & MECHANISM OF
THROMBOSIS FORMATION
Triad of Virchow
Thrombosis
Arterial Venous Arterial Venous Arterial
Thrombosis Thrombosis Thrombosis Thrombosis
Atherosclerosis
Iskemi kronik
Muskulatur atrofi
Bulu kaki rontok
Kuku hipertrofi dan pertumbuhan lambat
Nadi lemah
Temperatur
Vena superfisial menciut
Pengisian kapiler lambat
Pucat lebih lama dengan elevasi
Rubor
Skin gangrene in left hand and functional salvageable Th/ Amputation
ACC/AHA2005 ; TASCII,
CLINICAL STAGE :
TABLE 3 : CLASSIFICATION OF ACUTE LIMB
ISCHEMIA (ALI)
Catagory Description/Prognosis LOSS Doppler Test
Sensory Muscle Arterial Venous
I. Viable Not immediately None None Audible Audible
threatened
II Threatened
a. Marginally Salvageable if None or None In audible Audible
promptly treated min.(toes)
b. Immediately Salvageable if More than Inaudible Audible
imm.revascularization Mild,mod
toes, assc.
rest pain
III.Irreversible Major tissue Profound Prof.para Inaudible Inaudible
loss,permanent nerve Anesth. Lysis(rigor)
damaged
TASCII
DIFFERENTIAL DIAGNOSIS:
ACUTE OCCLUSSION CHRONIC OCCLUSSION
Acute Limb Ischemia : PAD
Arteria Embolism
Arterial Thrombosis Buerger Disease
Aneurysm of the
Blue Toe Syndr Popliteal art.
/Atheroembolism
Peripheral Art. AneurysmPopliteal Entrap Syndr.
Vasospastic Disorder (
Raynauds disease )
Thoracic Outlet Syndr.
APROACH & DIAGNOSIS :
ACC/AHA2005 ; TASCII
PAD MANAGEMENT :
Non pharmacologic :
1. Smoking cessation
2. Exercise therapy
Pharmacologic :
Thrombolytic Hyperhomocyteinemia
Antiplatelet therapy Hypertension
Diabetes Dislipidemia Anticoagulant :
UFH IV 80/kg BW or 5000U IV INFUS 18 U/kg/hr
; aPTT : 0,3 0, 7 IU/ml a Xa activity /1,52 X C OR
FIXED dose : IV 333 u / kg 250 U /kg bid
OR LMWH target aXA activity 0,3 0,7
VTE: deep vein thrombosis and
pulmonary embolism
Thrombosis is the formation PE occurs when parts of the clot
or presence of a thrombus detach and travel in the blood
that may obstruct blood flow to block vessels in the lungs
PE
through a vein or artery1
VTE occurs when Migration Embolus
thrombosis obstructs blood
flow through a vein
The term VTE
encompasses:
Thrombus
DVT
PE As the venous
clot grows, it
VTE is a serious health extends along
issue2 the vein
At autopsy,
approximately 63% of
DVT cases were
70% clinically undiagnosed2
A post-mortem
1. Stein PD, et al. Chest 1995;110:978-981.
2. Sandler DA, et al. J R Soc Med 1989;82:203-205. Goldhaber SZ, et al. Am. J. Med. 1982; 73: 822-826 DVT
Lensing AWA, et al. Lancet 1999; 353: 479-485
Lethen H, et al. Am. J. Cardiology 1997; 80: 1066-1069
Giradr P, et al. Chest 1999; 116: 903-908
Table II : Classical risk factors for
venousthromboembolism.
Strong risk factors (odds ratio >10)
trauma or fractures
major orthopaedic surgery
oncological surgery
Turkstra F, Kuijer PM, van Beek EJ, et al.. Ann Intern Med 1997;126:775-81.
Meignan M, Rosso J, Gauthier H, et al.. Arch Intern Med 2000;160:159-64.
Dobromirski M, Chen AT..Blood. 2012;120: 1562-9
Pulmonary Embolism
Diagnosis
Requires clinical suspicion!
High clinical suspicion demands immediate evaluation
Recognize Virchows Triad in every patient. Remember,
risk of acute death from PE 30% if untreated
Sign and symptoms neither sensitive nor specific.
Only 20% of patients with suspected PE will be found by
objective examinations to have PE
Pada EP, 30% pasien tidak diketahui/tak terdeteksi adanya faktor provoking
Hipoksemia tipikal pada EP AKUT is, TETAPI 40% pasien O2 SATURASI normal dan 20%
normal alveolar-arterial O2 gradien
Differential diagnosis of PE
Acute Myocardial Infarction
Aortic Dissection
Muskuloskeletal disorders
Obstructive pulmonary disease
Pericardial disease
Pneumonia
Pneumothorax
SIGN & SYMPTOMS:
Signs of right ventricular
dysfunction and pulmonary
hypertension, such as a loud
P2, right ventricular heave, and
elevated neck veins.
Gold standard
Invasive
Contrast dye
Availability
Karakteristik Klinis Pasien EP di Emergensi Unit
ECG:
Wanita , 40 thn KU: pleuritic chest pain
S1Q3T3; prominent S lead I, gel.Q & inverted T lead III, ST,
T inverted: leads V1 - V3, RBBB, defleksi amplitudo rendah
TREATMENT APPROACH :NT
ALGORITHM
TYPES AND AVAILABLE
ANTICOAGULANT / ANTITHROMBOTICS DRUGS
76
Targets for new-generation antithrombotic
agents in the coagulation cascade1 (2)
Initiation Tissue factor/VIIa Vitamin K antagonist:
Tecarfarin (Ph II completed)2
X IX
Indirect Factor Xa
inhibitors:
Direct Factor Xa inhibitors: VIIIa Idraparinux
Apixaban (Ph III completed)5,6 IXa (Ph III terminated)3
Rivaroxaban (Ph III completed)7 SSR 126517
Edoxaban (Ph III ongoing)8 Va (withdrawn 2009)4
Betrixaban (Ph II completed)9
Xa AT
Direct thrombin inhibitors:
Propagation Dabigatran etexilate
(Ph III completed)10
Fibrin formation II Thrombin Ximelagatran
(withdrawn 2006)11,12
AZD0837 (Ph II completed)13
Fibrinogen Fibrin
AT= antithrombin; Ph = Phase
1. Adapted from Turpie AG. Eur Heart J 2008;29:15565; 2. Ellis DJ et al. Circulation 2009;120:102935;
3. Bousser MG et al. Lancet 2008;371:31521; 4. NCT00580216; available at www.ClinicalTrials.gov; accessed March
2012; 5. Connolly SJ et al. N Engl J Med 2011;364:80617; 6. Granger CB et al. N Engl J Med 2011;365:98192;
7. Patel MR et al. N Engl J Med 2011;365:88391; 8. NCT00781391; available at www.ClinicalTrials.gov; accessed
March 2012; 9. NCT00742859; available at www.ClinicalTrials.gov; accessed March 2012; 10. Connolly SJ et al. N
Engl J Med 2009;361:113951; 11. Olsson SB et al. Lancet 2003;362:16918; 12. Albers GW et al. JAMA
2005;293:6908; 13. Lip GY et al. Eur Heart J 2009;30:2897907
Disclaimer: Apixaban and Edoxaban are not approved for clinical use in stroke prevention in atrial fibrillation. Rivaroxaban is approved in this indication only in the USA.
Dabigatran etexilate is now approved for clinical use in stroke prevention in atrial fibrillation in certain countries. Please check local prescribing information for further details
Evolving Anticoagulation Strategies
LMWH/Warfarin UFH/Warfarin
Overlapping
Bridge Bridge
LMWH to LMWH to
Switching Dabigatran Edoxaban
(RE-COVER) (HOKUSAI)
(N=8,250)