Pulmonary embolism !! The 3rd most common cardiovascular disease !!! According to autopsy only 30% correctly recognized while Mortality of recognized and treated PE is 8% non-recognized and not treated 30% 40-50% patients with DVT have asymptomatic PE !! Always consider possibility of PE !! Definition •Obstruction of part of pulmonary arterial system by • •trombus •fat •air •amniotic fluid • • Source •leg deep vein thrombosis (85%) •pelvic vein •renal vein •vena cava inferior •right heart •importance of vena cava sup. is increasing • ( central vein catheter, ICD, PM,….) • Risk factors - Virchow trias • Risk factors •Congenital •Acquired •Predisposing •Triggers • Congenital thrombofile RF •APC resistance - FV Leiden (homozyg.) •def. AT III, prot. C, prot. S, Fbg. •Von Willebrand (def. f VIII) •MTHFR •PT20210a •fibrinolysis disorders Acquired thrombofile RF • •immobilisation •surgery •Malignancy •myeloproliferation •hormone th., drugs (tamoxifen, leflunomid..) •chronic heart failure, lung disease •autoimmune dis. •infections • Predisposing RF •age •obesity •varices •history of thrombosis/VTE •anatomic abnormalities (May-Thurner, Paget-Schroetter) • Triggers Øtravelling Øtrauma Øvenous catheters Øpregnancy Øe-thrombosis… • Pathophysiologic concequences Extent localization status of cardiopulmonary system Hemodynamically significant PE causes acute pulmonary hypertension ® pressure elevation in right sided heart compartments ® dilatation, acute Tri insuf ® acute right heart failure, in case of massive PE also decrease of minute volume ® systemic hypotension. Irritation of „stretch“ receptors ® hyperventilation ® hypoxemia a hypocapnia Symptomes of PE acute X subacute (successive) high-risk (shock, ↓TK) vs. not high-risk Sudden death - cca 10% Dyspnea at rest - almost in 95 % - abrupt onset, abruptly worsened Chest pain - cca 50%, of any type Hemoptysis - only in case of pulmonary infarction - cca 15% Cought, syncope Clinical - tachypnea and tachycardia acute right heart failure hypotension cardiogenic shock Investigations •ECG •X-ray (not specific) •ECHO •pulmonary arteriography •spiral CT angiography •pulmonary scintigraphy •blood sample •duplex sono of leg veins – exclusion of thrombosis • • ECG •S I •Q III •Neg.T v III, V1 – V4 •Tachycardia •RBBB •Right axis deviation •P pulmonale in II, III • • RV hypertrophy is not typical for PE • • ECG ECHO •akinesia of the mid-free wall but normal motion of the apex •RV dilatation •D shape of left ventricular cavity during • contraction •doppler measurement of pulmonary flow •tricuspidal regurgitation • ECHO Laborathory •DDimers • - breakdown products of a blood clot • - negative ELISA test excludes TE process • - falsely positiv – infection, pregnancy, injury, • recent surgery • BNP • TropT •Astrup – hypoxemia, hypocapnia • • • CT AG •CT pulmonary angiography • high senzitivity and specificity • limitations: allergy • induced postcontrast nephrophaty • small peripheral arteries • pregnant patients (better than SPECT) • • CT AG SPECT •high sensitivity, low specificity ® negative scan excludes PE • •combined ventilation-perfusion scan, in comparison with chest X-ray, integration with orientation CT • SPECT Therapy of PE Opening of ocluded pulmonary arteries •Thrombolysis can be started up to 14 days since PE – indication criteria: hypotension, cardiog. shock - symptomes of right heart faulire - unsuccesful heparin therapy, increasing or recidivous KI – high risk of fatal bleeding •Anticoagulation - full anticoag. dose - UFH or LMWH - fondaparinux - warfarin - NOAC (dabigatran, rivaroxaban, apixaban, edoxaban) •Embolectomy – only several dept. all over the world •Catheter therapy Prevention of TED (TEN) Risk stratification before surgery Physical prevention - early mobilization, venous gymnastic (dorsal and plantar ankle flexion), elastic stockings, bandages Pharmacologic prevention - LMWH, fondaparinux Caval filter Email: Andrsova.Irena@fnbrno.cz