1. PULMONARY EMBOLISM PROF. DR. YESARİ KARTER KARTER

2. Pulmonary Embolism: Impaction of material into branches of the pulmonary arterial bed

3. Mortality- 50 000 death/year (decreasing) Hospitalisation: 300-600 000/year Male>Female American Africans old > young

4. RISK FACTORS - inherited - acquired

5. Inherited Risk Factors Family History (+) Acquired risk factor (-) Prior deep venous thrombosis

6. Inherited Risk Factors (2) -Antithrombin III deficiency -Protein C deficiency -Protein S deficiency -Protein C resistance (Factor V Leiden) -Hyperhomocystinemi -Abnormal fibrinogen -Abnormal fibrinolytic system

7. Acquired Risk Factors -surgery or trauma of pelvis/lower extremities -immobilization -surgery with >30 min general anesthesia -local tissue trauma and vessel destruction -pregnancy especialy in the puerperism and after cesarian section -estrogen therpy

8. Acquired Risk Factors (II) -Age > 40 -Malignity -Obesity -Heart Failure -Myocard infarction

9. Acquired Risk factors (III) -Prior DVT -Nephrotic Syndrome -Antiphospholipid Syndrome -PNH -Waldenström

10. Thromboembolic risk of the patient -Risk of the patient (acquired / inherited) -Risk of the clinical condition

11. Diagnose -Young patient -Family history (+) -Acquired risk factors (-) ___ inherited

12. Symptoms -Chest pain -Pleuritic pain -Dyspnea -Cough -Hemoptysis -Syncope

13. Laboratory Standart test ECG Chest rontgenography Arterial blood gases Echocardiography Imaging venous thrombus Imaging pulmoner emboli

14. Standart tests -Leucocytosis (infarctuse) -ESR increases -D-Dimer increases low---- Exclusion of PE

15. ECG Nonspesific changes -Massive emboli-----RV load Differential diagnosis -Myocardial infarctuse -Accelere atrial rythm Typical findings -RV strain -T (-) and or ST elevation (V1-3) -P pulmonale (right axis) -S1Q3T3

16. Chest Radiography Usually nonspesific Not sensitive or specific Proximal, large segmental artery Multiple small segmental artery

17. Chest Radiography (II) -Atelectasis -Elevation of the hemidiaphragm -Pleural efusion -Dilatation of the main branches of PA -Paranchymal densities (in the lower lung fields, pleural based) -Zones of oligemia

18. Arterial Blood Gases Acute PaCO2 decreases Massive PaO2 decreases Submassive Normal / Nearnormal

19. Echocardiography -Shows emboli in main pulmonary arteries, but not in lober and segmentary arteries -Dilated hypokinetic RV -Distorsion of the interventricular septum in diastole -Tricuspid regurgitation associated with increase in systolic pressure in pulmonary artery

20. Deep Vein Thrombosis -90% of PE originates from DVT (poplitea or proximal leg veins) -leg pain or swelling -Homan’s sign -signs of infection in subcutan veins

21. Deep Vein Thrombosis -Phlebography -Doppler

22. Imaging pulmonary emboli -Chest radiography -Ventilation-Perfusion Lung Scan -Pulmonary angiography -hCT -MR angiography

23. Ventilation-Perfusion Lung Scan Perfusion (-) and Ventilation (+) ---PE Perfusion (N) and Clinical sym and signs (N) ----PE excluded Low probability PVLS and low probability of clinical sym and signs ----PE excluded High probability PVLS and high probability of clinical symp and signs ---- Anticoagulation

24. Clinical Probability of acute PE -High Probability (80-100%) Risk factors (+) Dyspnea Tachypnea Chest pain Radiology (+) PaO2 decreases P (A-a)O2 increases -Intermediate Probability (20-79%) -Low Probability (1-19%) Risk Factors (-) Clinical and laboratory findings can be explained

25. D ichotomous clinical probability assesment: D ichotomous clinical probability assesment: PE likely > 4 PE likely > 4 Pe unlikely < 4 or = 4 Pe unlikely < 4 or = 4

26. PE likely--------h CT PE likely--------h CT ------normal----exclude ------normal----exclude ------findings (+)----PE ------findings (+)----PE ------indeterminate----LE US ------indeterminate----LE US PA PA PE unlikely-----D-dimer(+) PE unlikely-----D-dimer(+) -------h (CT) -------h (CT) D-dimer(-) D-dimer(-) -------exclude PE -------exclude PE

27. Pulmonary Angiography Gold standart İmages PE in subsegmental and peripheral arteries

28. hCT -two dimensional angiographic image -specifity 90% -dimension of the emboli -mediastinal and parenchymal patologies

29. MR Angiography Sensitivity-70 – 90 % Specifity- 77 – 100 % (Central arteries) Also asseses RV function

30. Treatment -to prevent death -to reduce morbidity -to prevent pulmoner hypertension progresing due to thromboemboli

31. Treatment (II) Supportive -Oxygen -IV liquid -Vasopressors

32. Anticoagulation -unfractioned heparin -LMWH -Thrombolysis -Embolectomy

33. Unfractioned Heparin IV 5000 U bolus + 30-35 000 U/kg aPTT- twice the control value -Thrombocytopeni early: thrombocyte agregation slight, reveresible, no need to stop late: antibodies against trombocytes arterial and venous thromboemboli -Osteopeni

34. LMWH -long acting -less binding to plasma protein -greater bioavailibity -no need monitorisation

35. Prognosis -Mortality rate – 30% -Depends on associated pathology -Resolution – 5 days 36% 2 weeks 52% 3 months 73% Pulmonary hypertension recurrent microemboli (rare)

36. Secondary prevention UFH + oral anticoagulan (6 months) LMWH SC + oral anticoagulan (6 months ) LMWH (pregnancy) Recurrance / unknown origin / permanantly increased risk (throughout life)

37. Thrombolysis Massive pulmoner emboli with hemodynamic instability -streptokinase -urokinase -t-PA **serious bleeding

38. REFERENCES: Agnelli G. Anticoagulation in the prevention and treatment of pulmonary embolism.Chest 1995. 107;39-44. Agnelli G. Anticoagulation in the prevention and treatment of pulmonary embolism.Chest 1995. 107;39-44. BellWR,Simon TL; DeMets DL. The clinical features of massive and submassive pulmonary embolism. Am J Med 1977; 62: 355-360. BellWR,Simon TL; DeMets DL. The clinical features of massive and submassive pulmonary embolism. Am J Med 1977; 62: 355-360. Braunwald E. Pulmonary embolism. Braunwald’s heart disease. Braunwald (ed)Philedalphia. WB Saunders 1992.562-1568. Braunwald E. Pulmonary embolism. Braunwald’s heart disease. Braunwald (ed)Philedalphia. WB Saunders 1992.562-1568. Herold CJ, Bankier AA, Burghaiber OC, Minar E, Watzke HH. Pulmonary Embolism. Comprehensive Pulmonary Medicine. Albert R, Spiro S, Jett J (eds). Harcaurt Brace and Company Limited London 1999. 50.1-50.12 Herold CJ, Bankier AA, Burghaiber OC, Minar E, Watzke HH. Pulmonary Embolism. Comprehensive Pulmonary Medicine. Albert R, Spiro S, Jett J (eds). Harcaurt Brace and Company Limited London 1999. 50.1-50.12 Hyers TH. Diagnosis of pulmonary embolism. Thorax 1995; 50: 930-932. Hyers TH. Diagnosis of pulmonary embolism. Thorax 1995; 50: 930-932. Lane D, Manucci PM, Bauer KA, et al. Inherited thrombophilia: Part I.Thromb Haemost 1996;76: 651-662. Lane D, Manucci PM, Bauer KA, et al. Inherited thrombophilia: Part I.Thromb Haemost 1996;76: 651-662. Remy -Jerden M, Remy J,Deschildre F. Diagnosis of pulmonary embolism with spiral CT: comparison with pulmonary angiography and scintigraphy. Radiology 1996; 200(3):699-706. Remy -Jerden M, Remy J,Deschildre F. Diagnosis of pulmonary embolism with spiral CT: comparison with pulmonary angiography and scintigraphy. Radiology 1996; 200(3):699-706.