1. DVT, Pulmonary Embolism
Rabih R. Azar, MD, MSc, FACC
Director of Cardiovascular Research
Hotel Dieu de France Hospital
Associate Professor of Medicine
Saint Joseph University School of Medicine

2. Hypercoagulable States Associated with DVT

4. Symptoms, Signs and Diagnosis of DVT
Leg pain
Most commonly:
mild discomfort on palpation of the lower calf
palpation of a venous cord
increase in the temperature of the calf
presence of non pitting edema
Homan’s sign
Blood tests:
Increased d-dimers
Imaging modalities:
Doppler of lower extremities

5. Pathophysiology of Pulmonary Embolism (1)
Obstruction of pulmonary vessel
Increase in pulmonary artery pressure
Release of vasoconstricting compounds (serotonin)
Reflex pulmonary vasoconstriction
Hypoxemia
Further increase in pulmonary vascular resistance and pulmonary hypertension
Dilatation of right ventricle

6. Pathophysiology of PE (2)
Vascular obstruction of pulmonary artery
Ventilation without perfusion = increase alveolar dead space = shunt = hypoxemia
Bronchoconstriction and increase airway resistance (due to secretion of vaso and broncho active substances such as serotonin)
Alveolar hyperventilation due to reflex stimulation of irritant receptors = hypocapnia

7. Hemodynamic Consequences of PE

9. Nonimaging Diagnostic Methods in PE
Plasma D-Dimers ELISA
Fibrin clot break-down
Sensitive but not specific
Sensitivity 96.4%, neg. predictive value 99.6%
Levels are increased: post op (1 week), MI, sepsis, cancer, any systemic illness
BNP
Increases in severe PE; not diagnostic
Troponin

10. Other Nonimaging Tests in PE
Arterial blood gases
Usually hypoxemia hypocapnia
However, not sensitive and not specific
In the PIOPED study: no difference between the average Pa02 among those with and those without PE (70 and 72 mm Hg)
In the subset of angiographically proven PE but no prior cardiopulmonary disease, 26% had a Pa02 > 80 mm Hg
Electrocardiogram
Sinus tachycardia, minor ST and T waves abnormalities or normal = most frequent senario
Less common but useful findings: negative T waves V1-V4 (RV ischemia), S1Q3T3 complex, incomplete or complet RBBB
Help exclude other conditions such as acute MI

11. Imaging Methods in the Diagnosis of PE
Chest X-Ray
Normal = most common
Focal oligemia = massive central embolic obstruction
Peripheral wedge-shaped density above the diaphragme
Distension of one of the pulmonary arteries
Multiplanar Chest CT
Most sensitive exam. Is now the standard for diagnosis of PE
Include scanning of the venous system from the popliteal veins to the subsegmental pulmonary arteries
Lung Scan
Second choice imaging test, reserved for patients with renal insufficiency, contrast allergy or pregnancy
Normal ventilation perfusion study; ventilation perfusion mismatch = high probability for PE
Pulmonary Angiography
Reserved for patients in who intervention is planned, such as suction catheter, embolectomy, mechanical clot fragmentation or catheter-directed thrombolysis

14. Diagnostic Strategy

16. Characteristics Associated With Cardiogenic Shock Secondary to Massive PE
Evidence of DVT or predisposing factors for DVT
Evidence of acute right sided heart failure:
Distended neck veins
S3 gallop
Right ventricular heave
Clear lungs
Echocardiographic finding of right ventricular dilatation or hypokinesis
ECG evidence of acute cor pulmonale manifested by a new S1Q3T3 pattern, new RBBB or right ventricular ischemia

18. Indications for Inferior Vena Cava Interruption
Major hemorrhage that precludes anti-coagulation
Recurrent PE despite well-documented anti-coagulation

19. Duration of anti-coagulation after DVT/PE
DVT or PE in the presence of major transient risk factor without a thrombophilia risk: 3-6 months of anti-coagulation
DVT or PE related to thrombophilia or a persistent underlying thrombotic risk (ie: cancer…) should receive long-term therapy (at least 1 year and likely indefinitely).
Prevention of DVT/PE
LMHW
Low dose coumadin
Subcutaneous unfractionated heparin
Direct thrombine inhibitors
Devices that perform intermittent pneumatic compression of the lower extremities

20. MAIN FEATURE: THE PRESENCE OF PULMONARY HYPERTENSION
COR PULMONALE
DILATATION/HYPERTROPHY OR RIGHT VENTRICLE SECONDARY TO LUNG DISEASE (PARENCHYMAL OR VASCULAR)
MAIN FEATURE: THE PRESENCE OF PULMONARY HYPERTENSION

21. Etiology of Chronic Cor Pulmonale Diseases Leading to Hypoxic Vasoconstriction 
Chronic bronchitis Chronic obstructive pulmonary disease Cystic fibrosis Chronic hypoventilation   Obesity   Neuromuscular disease   Chest wall dysfunction Living at high altitudes
Diseases That Cause Occlusion of the Pulmonary Vascular Bed 
Recurrent pulmonary thromboembolism Primary pulmonary hypertension Venocclusive disease Collagen vascular disease Drug induced lung disease
Diseases That Lead to Parenchymal Disease 
Chronic bronchitis Chronic obstructive pulmonary disease Bronchiectasis Cystic fibrosis Pneumoconiosis Sarcoid Idiopathic pulmonary fibrosis

22. Pathophysiology 1- Pulmonary hypertension 2- Dilation of RV
3- Decrease in cardiac output
4- Na and water retention

23. Signs Lungs: signs of the underlying disease.
Heart: dilated RV: parasternal lift, Harzer sign, pulmonary systolic click, increase in intensity of TR murmur with inspiration (Carvallo’s sign)
Jugular venous distension, hepatomegaly, oedema

24. Diagnosis of Cor Pulmonale
ECG: p pulmonale, RVH, right axis deviation
Echo: RV dilation, pulmonary hypertension, normal LV
Chest CT scan: underlying pulmonary disease