ASSESMENT OF PULMONARY THROMBOEMBOLISM

PATIENTS DIAGNOSED IN OUR CLINIC

A. Şimşek, G.Ö. Türkkan, K. Melek

F.Ö.Eyüboğlu

University of Baskent, Department of Chest Disease

INTRODUCTION

• Venous thromboemboli (VTE) is the third most common cardiovascular disease after the ischemic heart disease and stroke.

• The risk of PTE increases with advanced age

• It was seen in male and female with same ratio

PULMONARY THROMBOEMBOLISM (PTE)

• Annual incidence : 0.23-1.83/1000

• Mortality rate :– without treatment: 30 %– with treatment: 14.7

• Cause can not be identified at 19-47%

• Recurrance:– First year: 7-8 %

– After 8-10 years: 30 %

RISK FACTORS FOR PTE

• Immobilization• Malignancy

• Trauma• Advanced age• Cardiopulmonary dis.

• Surgery• Previous VTE• Obesity• Cerebrovasculary disease• OC usage

ACQUIRED RISK FACTORS

RISK FACTORS

• Antiphospholipid Antibody Synd

• Prothrombin 20210 A mut.

• Increased Lipoprotein A • Methylentetrahydrofolate

reductase mutation(?)

GENETIC RISK FACTORS

• Antithrombin III deff

• Protein C defficiency

• Protein S defficiency

• FV Leiden mutation

• Hyperhomocysteinemie

AIM

The aim of this study was to define risk factors for PTE, clinical characteristics, demographic data of subjects, diagnostic procedures, and treatment responses

MATERIAL AND METHOD

We retrospectively analysed data from 164 patients admitted to our clinic with PTE in our hospital between 2000 to 2005

MATERIAL AND METHOD • Sex• Age• Risk factors• Symptoms• Thorax CT• Lower extremities

venous doppler US

MATERIAL AND METHOD

• Severity of PTE

• Drugs used for treatment

• Mortality rate

• Recurrance rate

RESULTS

• Female ratio : 55.5 %• Male ratio : 44.5 %

• Mean Age : - Female : 69.3 ± 13.6 - Male : 62.7 ± 18.3 - General : 66.3 ± 16.1

RESULTS

• Risk factors for PTE were absent in 25.6% of patients (idiopathic)

29,9%

15,2%

1,2%0,6%

12,5%

6,1%9,2%

28%

16,5% Immobilization

Surgery

Heart Failure

Malignancy

Trauma

Previous VTE

OralContraceptiveVasculitis

Cerebrovasculary disease

RISK FACTORS FOR PTE

2,1%

4,5% 4,5%6,5%

6,5%

8,7%

10,8%13%

39%

Lower extremitysurgeryThorax-lumbalsurgeryGynecologicalsurgeryCoronary arterialbypass graftAbdominoplasty

Urological surgery

Cranial

Aorta surgery

Cataract surgery

Rectum Surgery

Mastectomy

Tympanectomy

SURGERY TYPE

13,6%

18,1%

4,5% 9%9%

13,6%

13,6%13,6%

Prostate

Liver

Breast

Heamatologic

GIS

Lung

Gynecologic

Surrenal

MALIGNANCY

76.2

50

26.823.8

15.914.6 148.5 6.1

01020304050607080 Dyspnea

Chest pain

Edema,rednessat extremitiesCough

Fever

Weakness

Sputum

hemoptysis

syncope

SYMPTOMS

38,4

16,5

11,6

84,8

63,6

4,2

33,1

11,9

0 20 40 60 80 100

Tachycardia

Hypotention

Tacypnea

Hypoxia

Hypocapnia

Hypercapnia

Res.alcalosis

Acidosis

Arterial blood gasesPhysical examination

SIGNS

Bilateral embolism 70.7 %

Unilateral embolism

- Right

- Left

29.3 %

61.4 %

38.6 %

LOCALIZATION OF PTE

Minör embolism 62.3 %

Submassive embolism 21 %

Massive embolism 16.7 %

SEVERITY OF PTE

THROMBUS (+) 45.6 %

THROMBUS (-) 54.4 %

BILATERAL 23.5 %

UNILATERAL -RIGHT -LEFT

76.5 % - 59.6 % - 40.3 %

PRESENCE OF LOWER EXTREMİTES VENOUS THROMBUS

The ratio of cardiac thrombus was 5.5 %

Heparin 68.3 %

Low moleculer weight heparin

43.3 %

Warfarin 84.8 %

Thrombolytic drugs 9.8 %

DRUGS USED FOR TREATMENT

Mortality 11 %

Recurrance 14.8 %

FOLLOW UP

DISCUSSION

• Most frequently seen risk factors– Immobilization– Surgery

• Most frequently seen surgery

Sugery to lower extremities

Idiopathic Immobilisation Surgery Malignancy Heart Failure

Trauma Previous VTE

ICOPER(1999)

19 % 28.1 % 28.9 % 22.5 % 10.5 % 11.2 % 24.9 %

Heit et al.(2000)

26 % 59 % 24 % 18 % 10 % 12 % 5 %

Cushman et al(2001)

47 % 25 % 25 %

Richard at al(2003)

41 % 23 % 18 % 2 %

Present Study( 2007)

25.6 % 29.9 % 28 % 12.8 % 16.5 % 9.2 % 6.1 %

RISK FACTORS FOR PULMONARY EMBOLISM

Prostate CA

Liver CA Breast CA Lung CA Colon CA Pancreas CA

Rickler ve ark.(1983)

6.5 % 2 % 25.6 % 15.2 % 17.4 %

Levitan et al(1999)

17 % 21 % 18 %

Kolomansky et al(2006)

14 % 16 % 11 % 10 %

Present Study(2007)

18.1 % 13.6 % 13.6 % 9 % 4.5 %

MALIGNANCY RATES IN PULMONARY THROMBOEMBOLISM

In this study;

• Lung and rectum cancer rates were lower than other studies

• Liver cancer rate was higher than other studies

• Pancreas cancer was not seen anymore

• According to our study, all malignancies can cause PTE

• Our hospital is a solid organ transplantation center, for that reason liver cancer rate might be found high

• Lower ext. thrombus rate

• Cardiac thrombus rateSimilar with literature

Recurrance rate was higher than literature

Recurrance Rate(%)

Prandoni et al (1996) 8.6 %

ICOPER (1999) 7.9 %

Hansson et al (2000) 7 %

Heit et al (2000) 12.9 %

Cushman et al (2001) 7.7 %

Our study (2007) 14.8 %

RECURRANCE RATE IN PULMONARY EMBOLISM

• The reason of high recurrance rate of PTE in our study may be associated with long term (5 year) follow up

• Long term follow up is more informative than 6-12 months follow up in determining recurrance rate

• Mortality rate was lower than literature

• Early diagnosis• Early treatment• Long term follow up

Effective in determining low mortality rates

Mortality Rate (%)

Anderson et al (1991) 25 %

ICOPER (1999) 17.4 %

Cushman et al (2001) 15.1 %

Murin et al (2002) 14.7 %

Our study (2007) 11 %

MORTALITY RATES IN PULMONARY EMBOLISM

RESULTS In order to determine correct recurrance

rates, 5 year follow up is necessary Long term and near follow up may reduce

mortality In presence of malignancy, VTE should be

kept in mind as a complication Because of high rate of idiopathic PTE,

hereditary thrombophylic factors should be searched in all patients