Pulmonary embolism Martin Radvan Thrombembolic disease ⚫ Deep vein thrombosis ⚫ Pulmonary embolism Thrombembolic disease ⚫ Imobilization ⚫ Major surgery ⚫ Trauma ⚫ Age ⚫ Heart failure ⚫ Pregnancy ⚫ Genetic factors Thrombembolic disease ⚫ Incidence: 100-200/100 000 ⚫ EU – 1500000/year; 60% in hospital ⚫ 3rd most common cause of CV death ⚫ Acute vs longtherm therapy ⚫ Prophylaxis Thrombembolic disease ⚫ Acute therapy (10d) ⚫ Consequent therapy (3-6m) ⚫ Chronic therapy (prophylaxis after 6m) ⚫ Idiopathic TED: 20-30% recidiv./10 years ⚫ Onkologic patients – LMWH, edoxaban Marik PE, Cavallazzi R. Extended anticoagulant and aspirin treatment for the secondary prevention of thromboembolic disease: a systematic review and meta-analysis. PLoS One. 2015;10:e0143252 Case report ⚫ Marie K., 85 years ⚫ On emergency for breathing problems, vomiting ⚫ BP 90/60mmHg, HR 130-180/min ⚫ Atrial fibrilation ⚫ Blood saturation 70% ⚫ Breathing rate 30/min Case report – clinical findings ⚫ Marie K., 85 years ⚫ Somnolence ⚫ Dehydratation, but elevated jugular veins ⚫ clear breathing ⚫ no murmur ⚫ both legs swelling, more on the right side Case report - history ⚫ Marie K., 85 years ⚫ HFpEF, chronic moderate pulmonary hypertension (PASP 55mmHg, EF LK 60% ⚫ Permanent atrial fibrilation on ASA ⚫ Parkinsons syndrome ⚫ Hypomobility ⚫ Diabetes, obesity ⚫ Arterial hypertensionon Case report - labs ⚫ Leu 14,4.109/l, Hb 120 g/l, PLT 225.109/l ⚫ urea 4,35mmol/l, kreat 97mmol/l ⚫ CRP 153 mg/l ⚫ troponin T 0,099ng/ml (norma do 0,029) ⚫ D-dimery 25,75mg/l (norma do 0,5) ⚫ INR 1,4, fibrinogen 5,16 g/l, aptt-r 1,16 What would you do? What would you do? ⚫ ECG What would you do? ⚫ ECG ⚫ X-ray What would you do? ⚫ ECG ⚫ X-ray ⚫ Doppler sonography What would you do? ⚫ ECG ⚫ X-ray ⚫ Doppler sonography ⚫ CT angiography What would you do? ⚫ ECG ⚫ X-ray ⚫ Doppler sonography ⚫ CT angiography ⚫ Scintigraphy What would you do? ⚫ ECG ⚫ X-ray ⚫ Doppler sonography ⚫ CT angiography ⚫ Scintigraphy ⚫ echocardiography Pulmonary embolism ⚫ High risk (massive) – shock, sBP < 90mmHg, bradycardia ⚫ Intermediate risk (submassive) – without hypotension, but evidence of right ventricle dysfunction, cardiomarkers ⚫ Low risk (small) – all other Therapy ⚫ Thrombolysis for massive in absence of contraindications ⚫ Embolectomy ⚫ Anticoagulation ⚫ Caval filters Therapy ⚫ Thrombolysis for massive in absence of contraindications ⚫ Embolectomy ⚫ Anticoagulation ⚫ Caval filters Anticoagulation ⚫ Heparin ⚫ LMWH ⚫ Warfarin ⚫ Dabigatran ⚫ Rivaroxaban, apixaban, edoxaban Target INR (2.0-3.0) <1.5 1.5–1.9 2.0–2.5 2.6–3.0 3.1–3.5 3.6-4.0 4.1-4.5 >4.5 0 20 40 60 80 Cases/1000patients/year Intracranial bleeding Stroke Warfarin and risk balance Warfarin vs DOACs ⚫ Same effect ⚫ 50% decrease of intracranial bleeding ⚫ Easier for patients ⚫ No diet, no blood controls, almost no drug-drug interactions Risk factors for extended anticoagulation ⚫ Idiopathic x secondary ⚫ Proxymal x distal ⚫ Pulmonary embolism x deep vein thrombosis ⚫ Residual thrombosis ⚫ D-dimer test ⚫ Pregnancy, hormonal therapy, cancer… Závěr ❖ Pulmonary embolism is common ❖ Prophylaxis for in hospital patients ❖ Mortality is low, when the diagnosis is known ❖ Bed side diagnosis is feasible in criticaly ill patients ❖ Risk stratification ❖ Long therm therapy Thx for attention