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ราชวิทยาลัยอายุรแพทย์วิชาการสัญจรจังหวัดอุบลราชธานี 2558
Topic to cover
What is pulmonary embolism?
Pathophysiology
Clinical manifestation
Investigation
Strategies management
Thai data
Summary
What is pulmonary embolism?
https://en.wikipedia.org/wiki/Pulmonary_embolism
Endothelial damage
Dysfunction
• Smoking Stasis
• Hypertension Immobilization
Injury
Polycythemia
• Surgery Virchow’s
• Trauma triad
• Catheter Hypercoaulability
Heriditary
• Factor V Leiden
• Antithrombin def
• Protien C //S def
Acquired
Rudolph Virchow • Cancer
• ChemoRx
• OCR/HRT
• pregnancy
Hemodynamic Mechanical
Main vessel
consequence occlusion
Virchow’s RV afterload segmental
triad vessel
Peripheral Chemical
vessel mediators
DVT Pleuritic CP
Reflex
bronchoconstriction
Pulmonary
embolism
V/Q
mismatch
Hypoxemia
Clinical manifestation
Pulmonary embolism (PE) has a wide variety
of presenting features, ranging from no
symptoms to shock or sudden death.
Dyspnea at rest or with exertion (73 %)
Pleuritic pain (44 %)
Cough (37 %)
Orthopnea (28 %)
Calf or thigh pain and/or swelling (44 %)
Wheezing (21 %)
Hemoptysis (13 %)
Clinical signs
Common presenting signs on examination include :
Tachypnea (54 %)
Calf or thigh swelling, erythema, edema,
tenderness, palpable cords (47 %)
Tachycardia (24 %)
Rales (18 %)
Decreased breath sounds (17 %)
Lound P2(15 %)
Jugular venous distension (14 %)
Fever, mimicking pneumonia (3 %)
Circulatory collapse is uncommon (8 %)
Hemodynamically unstable and stable
PE (massive or submassive)
Hemodynamically unstable PE is that which results in
hypotension.
Hypotension is defined as a SBP <90 mmHg for a period >15
minutes or that requiring vasopressors or inotropic support
and not explained by other causes
Hemodynamically stable PE is defined as PE that does not
meet the definition of hemodynamically unstable PE.
There is a spectrum of severity within this population
ranging from patients who present with small asymptomatic
PE to those who present with mild or borderline hypotension
that stabilizes in response to fluid therapy, or those who
present with right ventricle dysfunction (also known as
“intermediate” PE).
Approach to suspicious of PE
Hemodynamically stable, we suggest an approach
which combines clinical and pretest probability
assessment, D-dimer testing, and definitive
diagnostic imaging
Definitive imaging includes CT PA and V/Q
scanning
Hemodynamically unstable and in whom
definitive imaging is unsafe, bedside
echocardiography may be used to obtain a
presumptive diagnosis of PE
Chest radiography
EKG
Echocardiography
S D
V/Q scan
CTPA
U/S leg
Short axis Power Doppler image showing the right common femoral artery (RCFA) and the
non-compressible right femoral vein (RCFV), surrounded by hypoechogenic tissue
consisting of perivascular hematoma, at first suspected to represent deep vein thrombosis
(DVT).
Lønnebakken et al. Cardiovascular Ultrasound 2009 7:14
Head drop sign
III-V
suspectedhigh-risk acute PE (presence of shock or hypotension), emergent
computed tomography (CT) angiography or bedside transthoracic
echocardiography is recommended for diagnostic purposes (Class I).
Pulmonary angiography may be considered in unstable patients referred
directly to a catheterization laboratory to exclude acute coronary
syndromes (Class IIb).
suspectedacute PE without shock or hypotension, use of a validated risk
stratification scheme (e.g., Modified Well’s or Revised Geneva scores) should
be employed (Class I).
If
pretest probability is low or intermediate, D-dimer test should be used in
outpatient and emergency department settings (Class I). Low pretest
probability and a negative D-dimer test excludes acute PE (Class I). D-dimer
testing is not recommended in patients with a high pretest probability for
acute PE (Class III).
NormalCT angiography excludes PE in patients with low or intermediate
pretest probability (Class I). Normal perfusion lung scintigram (V/Q scan)
excludes acute PE (Class I).
Lower limb compression ultrasound with a proximal deep venous thrombosis
(DVT) in a patient with a clinically suspected PE confirms the diagnosis of
acute PE (Class I).
acutePE patients without shock or hypotension, use of the PESI or sPESI score
can be considered to distinguish between low- and intermediate-risk PE
(Class IIa). Similarly, assessment of the right ventricle with echocardiography
or CT, along with assessment of myocardial injury (usually troponin testing),
can be considered for further risk stratification (Class IIa).
patients with high-risk acute PE (shock or hypotension), initial therapy
should include intravenous anticoagulation with unfractionated heparin
(Class I) and thrombolytic therapy (Class I). Surgical pulmonary embolectomy
is recommended in patients with a contraindication to thrombolysis or when
thrombolytic therapy has failed (Class I).
Intermediate- or low-risk acute PE, initiation of parenteral
anticoagulation is recommended (Class I). Use of low molecular weight
heparin (LMWH) or fondaparinux is recommended for most patients (Class I).
In parallel to parenteral anticoagulation, treatment with warfarin
(international normalized ratio [INR] goal 2-3) is recommended (Class I).
Rivaroxaban (15 mg twice a day for 3 weeks, then 20 mg daily) or apixaban (10
mg twice a day for 7 days, then 5 mg twice a day) are alternatives to the
combination of parenteral and warfarin anticoagulation (Class I for both).
Inplace of warfarin, dabigatran (150 mg twice a day, 110 mg twice a day for
patients ≥80 or taking verapamil) is recommended following the acute phase
of parenteral anticoagulation (Class I).
Neworal anticoagulants (dabigatran, rivaroxaban and apixaban) are not
recommended in patients with severe renal impairment (Class III)
Oral anticoagulant
oral anticoagulant ชนิดใหม่ที่ สามารถใช้ในการรักษา acute PE อาทิเช่น
dabigatran ซึ่งเป็น direct thrombin inhibitor สามารถใช้ได้ภายหลัง bridging therapy
ใน acute phase treatment และยังใช้ตอ ่ เนือ
่ งได้ใน early maintenance phase และ
long-term prevention เพื่อ ป้องกันการกลับเป็น VTE ซ้้าโดยไม่เพิม ่ ความเสีย
่ งต่อการเกิด
เลือดออกเมือ
่ เทียบกับ warfarin
rivaroxaban และ apixaban เป็นยาในกลุม่ direct factor Xa inhibitor ซึ่งสามารถ ใช้
แทน bridging therapy ได้และยังสามารถใช้ตอ ่ เนือ
่ งได้ใน early maintenance phase
กระทัง่ ถึง long-term prevention โดยไม่เพิม
่ ความเสีย ่ งในการเกิดเลือดออกเมือ
่ เทียบกับ
การรักษามาตรฐานเช่นกัน
U.S. FDA ได้ให้การรับรอง dabigatran, rivaroxaban และ apixaban เพือ ่ ใช้ในการรักษา
acute PE และป้องกันการเกิด VTE ซ้้า ข้อดีของยากลุม
่ ใหม่นค ี้ อ
ื เป็น oral therapy ที่ไม่
จ้าเป็นต้องท้าการตรวจ เพื่อติดตามระดับของยา แต่ยามีขอ
้ จ้ากัดส้าหรับการใช้ใน ผู้ป่วยทีม ่ ี
การท้างานของไตบกพร่องค่อนข้างรุนแรง
บูรพา ปุสธรรม บทฟื ้ นฟูวชิ าการ
Routine
use of systemic thrombolytic therapy is not recommended in
low- and intermediate-risk acute PE patients (Class III).
Thrombolytic therapy can be considered in patients with
intermediate- to high-risk acute PE with clinical signs of
hemodynamic decompensation (Class IIa).
Patientswith low-risk acute PE should be considered for early
discharge and continuation of treatment at home if proper outpatient
care and anticoagulation therapy can be arranged (Class IIa).
Routineuse of inferior vena cava (IVC) filters in patients with acute
PE is not recommended (Class III). IVC filters can be considered in
patients with a contraindication to anticoagulation (Class IIa) or with
recurrence of PE despite therapeutic anticoagulation (Class IIa).
Anticoagulation should be given for 3 months in all patients
(Class I). Indefinite treatment is recommended for patients
with a recurrent unprovoked PE (Class I), and considered for
patients with a first unprovoked PE and low risk of bleeding
(Class IIa). In patients with acute PE and cancer, consider
administering weight-adjusted LMWH for the first 3-6
months (Class IIa).
All patients with chronic thromboembolic pulmonary
hypertension (CTEPH) should be assessed for potential
operability by a multidisciplinary team (Class I), and should
receive life-long anticoagulation (Class I). Riociguat is
recommended for symptomatic CTEPH patients who are
inoperable (Class I).
Clinical characteristics and outcome of Thai
patients with acute pulmonary embolism
Cross-sectional study
OBJECTIVES:
To evaluate common risk factors, symptoms, signs, commonly used investigations,
treatment and outcome of Thai patients with APE.
To compare the clinical characteristics of non-massive and massive APE patients.
To identify the clinical characteristics and treatment that may predict the mortality of
massive APE.
MATERIAL AND METHOD:
All patients with confirmed APE diagnoses who were admitted to Siriraj Hospital,
Bangkok, Thailand between January 2001 and October 2005 were selected for
analysis in the present study. All APE patients' data, including demographics,
symptoms, signs, investigations, treatments, outcome and risk factors such as
malignancy, surgery, immobilization, and congenital thrombophilia, were recorded.
J Med assoc Thai, 2007 Nov;90 Suppl 2:59-67
RESULTS:
71 patients had a confirmed diagnosis of APE, 22 patients were male and 49 were
female. 14 patients were diagnosed with massive APE. The ages of patients varied
from 16 to 90 years old. The mean age was 50 +/- 2.2 years old. The most common
presenting symptoms and signs were dyspnea (92%), followed by tachypnea (63%)
and tachycardia (54%).
Idiopathic APE was found in 42.2% of the patients. Malignancy, especially
adenocarcinoma, was the most frequent risk factor (21%). The most frequent
radiographic abnormalities noted in the present study were pulmonary parenchymal
lesions (23.9%). Echocardiography findings were mostly elevated right ventricular
systolic pressure (RVSP), ranging from 18.5 to 98 mmHg (mean RVSP of 54.4 mmHg).
The most frequent diagnostic test used was ventilation-perfusion lung scan. Elevated
serum troponin-T seemed to be more frequent in the massive APE group. In the non-
survivor group, the author found hypotension and underlying malignancy statistically
significant different from the survivor group.
Clinical characteristics and outcome of Thai
patients with acute pulmonary embolism
CONCLUSION:
APE was not infrequent. Characteristics of APE patients in Thailand were not
different from previous reports in European countries. Malignancy seemed to
be the most frequent risk factors of APE in the present study population.
Troponin-T measurement may be useful to predict progression of APE.