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  • Pulmonary Embolism - Iswanto Pratanu, MD, FIHA PDF

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    DVT VTE PE o Acute PE is the most serious clinical presentation of VTE o incidence of 100-200 per 100 000 inhabitants o mortality rate 15% in the first 3 months after diagnosis o the epidemiology of PE is difficult to determine asymptomatic. CARDIOVASCULAR EMERGENCIES COURSE 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism.

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    DVT VTE PE o Acute PE is the most serious clinical presentation of VTE o incidence of 100-200 per 100 000 inhabitants o mortality rate 15% in the first 3 months after diagnosis o the epidemiology of PE is difficult to determine asymptomatic. CARDIOVASCULAR EMERGENCIES COURSE 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism.

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    22 tayangan30 halaman

    Pulmonary Embolism - Iswanto Pratanu, MD, FIHA PDF

    Diunggah oleh

    bagir_dm10
    DVT VTE PE o Acute PE is the most serious clinical presentation of VTE o incidence of 100-200 per 100 000 inhabitants o mortality rate 15% in the first 3 months after diagnosis o the epidemiology of PE is difficult to determine asymptomatic. CARDIOVASCULAR EMERGENCIES COURSE 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism.

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    dari 30

    PULMONARY

    EMBOLISM
    ISWANTO PRATANU

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Introduction
    DVT
    VTE
    PE

    o Acute PE is the most


    serious clinical
    presentation of VTE
    o incidence of 100200 per
    100 000 inhabitants
    o mortality rate 15% in the
    first 3 months after
    diagnosis
    o The epidemiology of PE
    is difficult to determine
    asymptomatic
    (Goldhaber 2003 Merrigan 2013)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Risk Factor
    o Immobilization
    o Travel of 4 hours or more in the past month
    o Surgery within the last 3 months
    o Malignancy (17%)
    o History thromboplebitis
    o Trauma to lower extremities and pelvis during past 3 mos
    o Smoking
    o Central venous instrumentation within past 3 months
    o Stroke
    o Prior pulmonary embolism
    o Heart failure
    o COPD
    o Hypercoagulable states (hereditary)
    o Hormonal therapy
    (Stein 2007) (Ouelette DR 2015)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Pathophysiology
    Embolus

    Circulation

    Chemical factors

    Neurohormonals

    Pulmonary vascular
    obstruction

    Vasoconstriction

    pulmonary resistance

    compliance artery

    PE

    RV dilatations
    Gas exchange

    (Goldhaber 2003,
    Konstantinides 2014)

    Desaturation

    CO

    RV heart failure

    Disturbance
    ventilationHypoxemia
    perfusion
    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    2014 ESC Guidelines on the diagnosis and management of acute


    pulmonary embolism

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Diagnosis
    Clinical manifestation of PE is not specific
    Suspected PE:
    Dyspneu
    Chest pain
    Presyncope or syncope
    Haemoptysis (coughing up blood)
    Palpitations
    Leg swelling and discomfort
    (Goldhaber 2003)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED)


    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    (Konstantinides 2014)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Scoring system

    (Wells 2000)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Scoring system

    (La Gal 2006)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Laboratory Test
    D-Dimer
    Suspected low or
    intermediate risk of
    PE
    ELISA method:
    sensitivity 95%
    Specificity decreased
    almost 10% in >80
    years old
    (Vyas 2012, Konstantinides 2014)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Laboratory Test
    BNP
    Increase in about 50% PE patients
    Higher sensitivity as indicator in heart failure

    Troponin I or T
    Increase in PE patients

    (Binder 2005, Lankeit 2013, Konstantinides 2012)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Imaging Test

    Joseph, Nicholas JR. CE Essentials

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Imaging Test
    Echocardiography
    Detect morphology dan function changes of RV
    Prognostic value in unstable haemodynamics
    patients is still the best
    No sign of RV overload or dysfunction exclude
    suspected high risk PE

    (Konstantinides 2014)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Thrombus

    Thrombus
    Thrombus

    Thrombus

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Imaging Test
    CT Angiography
    Standart imaging for
    patient with
    suspected PE
    Adequate imaging
    pulmonary vascular
    to segmental level
    MDCT giving
    imaging of thrombus
    in pulmonary
    vascular, detect RV
    dilatation and RV
    dysfunction
    (Lucassen 2013, Konstantinides 2014)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    (Konstantinides 2014)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    (Konstantinides 2014)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Therapy
    Haemodynamic and Respiratory Support
    Supportive treatment is vital acute RV failure
    low systemic output cause of death
    Modest (500 ml) fluid challenge help increase
    cardiac index
    Vasopresor is often necessary
    NE improves RV function via direct positive inotropic
    effect
    Dobutamine or dopamine considered for patient with
    low cardiac index and normal BP
    (Konstantinides 2014)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Therapy
    Anticoagulation
    Recommended to
    prevent early death and
    recurrent symptomatic
    or fatal VTE
    Standard duration at
    least 3 months
    Acute phase treatment
    consist of parenteral
    UFH, LMWH or
    fondaparinux over first
    5-10 days
    (Quinlan 2004, Buller2012)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Therapy -- Thrombolysis

    (Konstatinides 2012, Lavorini 2013)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Therapy
    Systemic thrombolysis is not routinely
    recommended as primary treatment for patients
    with intermediate-high risk PE, but should be
    considered if clinical signs of haemodynamic
    decompensation appear
    Percutaneous catheter-directed treatment or
    surgical pulmonary embolectomy are
    alternative rescue procedures for intermediatehigh risk PE
    (Konstatinides 2012, Lavorini 2013)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Prognostic

    (Jimenez 2010)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Prognostic

    (Jimenez 2010, Konstatinides 2014)

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    Summary
    PE has high morbidity and mortality
    The diagnose of PE is difficult to determine
    because remain asymptomatic
    Risk stratification need to be done for
    suspected PE to determine diagnosis and
    therapy
    With prompt diagnosis and management,
    recurrent PE and mortality could be prevented
    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

    THANK YOU

    CARDIOVASCULAR EMERGENCIES COURSE

    Bumi Surabaya Hotel, November 7-8th, 2015

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