pulmonary embolism /pulmonary hypertension …...pe introduction source of emboli pathogenesis &...
TRANSCRIPT
![Page 1: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/1.jpg)
Pulmonary Embolism /Pulmonary hypertension Khaled Al Oweidat, MD
![Page 2: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/2.jpg)
PE
Introduction
Source of emboli
Pathogenesis & Risk factors
S&S
Management approach:
- Assess clinical probability
-Assess risk of mortality
-Investigation
* Diagnostic
*Non diagnostic ( helpful test)
-Treatment (medications and duration of treatment)
![Page 3: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/3.jpg)
Introduction
• Partial or complete occlusion of a pulmonary arterial branch by blood clot(thrombus or multiple thrombi).
• Deep vein thrombosis and PE are different presentations of the same underlying pathophysiological event, venous thromboembolism (VTE).
• The annual incidence rate of VTE ranges between 75 and 269
cases per 100,000 persons (North America ,Western Europe)
![Page 4: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/4.jpg)
• VTE is the third most common cardiovascular condition after ACS and stroke
• lack of public awareness *(not like stroke and ACS)
• PE is a major cause of death in the United States, with estimated annual incidence of VTE about one episode per 1000 patients.
• PE is difficult to determine because it may remain asymptomatic, or its diagnosis may be an incidental finding; in some cases, the first presentation of PE may be sudden death.
![Page 5: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/5.jpg)
Source of emboli
• Thrombotic
- Most cases (80–95 percent) as a result of thrombus originating in the lower extremity
- Most thrombi originate in the deep veins of the calf and propagate proximally to the popliteal and femoral veins.
- Calf-limited thrombi pose a minimal embolic risk
- Emboli may also originate from upper-extremity thrombosis associated with central venous catheters or intravascular cardiac 2*devices, or may be associated with thoracic outlet obstruction or effort thrombosis
![Page 6: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/6.jpg)
Non thrombotic
![Page 7: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/7.jpg)
![Page 8: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/8.jpg)
![Page 9: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/9.jpg)
![Page 10: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/10.jpg)
Once detached from their point of origin, emboli travel via the
systemic venous system, through the right chambers of
the heart, and eventually reach the pulmonary arterial system.
Physiologic effects and clinical consequences of pulmonary
thromboembolism vary widely, ranging from asymptomatic
disease to hemodynamic collapse and death
![Page 11: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/11.jpg)
• Major factors that determine the outcomeinclude:
(1) size and location of emboli
(2) coexisting cardiopulmonary diseases
(3) secondary humoral mediator release and vascular hypoxic responses
(4) the rate of resolution of emboli.
![Page 12: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/12.jpg)
Hemodynamic consequences
![Page 13: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/13.jpg)
Gas exchange abnormality
• Gas exchange abnormalities
– Right to left shunt
Leads to…
• Hypoxemia
• Increased A–a gradient.
– V/Q mismatch.
– Increased dead space
– Respiratory alkalosis from hyperventilation
• Often a sign of increased dead space and impaired minute ventilation
• may suggest massive PE
![Page 14: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/14.jpg)
S&S
![Page 15: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/15.jpg)
![Page 16: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/16.jpg)
Management approach
• Assess clinical probability
• Assess risk of mortality
• Investigation
- Diagnostic
- Non diagnostic ( helpful test)
• Treatment (medications and duration of treatment)
![Page 17: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/17.jpg)
![Page 18: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/18.jpg)
![Page 19: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/19.jpg)
Assess risk of mortality
• High Risk:
- Hemodynamically Unstable with SBP<90 mmHg or drop in SBP>45mmHg IN 15 minutes.
- Early mortality is 15%.
• Non High Risk ( According to RVD and Myocardial injury)
- Intermediate Risk
- Low Risk
![Page 20: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/20.jpg)
![Page 21: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/21.jpg)
![Page 22: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/22.jpg)
![Page 23: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/23.jpg)
![Page 24: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/24.jpg)
![Page 25: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/25.jpg)
Diagnostic investigation
• D-dimer
- Non specific measure of fibrinolysis
• High sensitivity (positive in presence of dx)
• High negative predictive value (dx is absent when test is negative) in the outpatient setting
-Useful in outpatient setting/emergency room, not an inpatient test for ruling out PE
![Page 26: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/26.jpg)
V/Q scan
• Currently reserved for
• Renal impairment
• IV contrast allergies
• Pregnancy
• Hospital resources
![Page 27: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/27.jpg)
![Page 28: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/28.jpg)
CT with PE protocol
• Spiral CT
• Larger dose of Contrast
• Rapid rate of contrast
• Effective dose at pulmonary CT angiography, without significant loss of objective or subjective image quality.
![Page 29: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/29.jpg)
![Page 30: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/30.jpg)
![Page 31: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/31.jpg)
Electrocardiogram demonstrating findings consistent with embolism including sinus tachycardia, incomplete right bundle branch block, S1Q3T3 pattern, and inverted precordial T waves.(minority of patients)
![Page 32: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/32.jpg)
Others
• CXR:
Most patients with pulmonary embolism have abnormal
but nonspecific chest radiographic findings
• Echocardiogram:
Suspected massive pulmonary embolism who are too ill for transportation or
have an absolute contraindication to the administration of a contrast agent.
• Troponin :
Increase in right heart strain .
![Page 33: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/33.jpg)
Treatment
• New oral anticoagulants(NOACs) were recommended in the 2014 ESC Guidelines as an alternative to the standard heparin/VKA(warfarian) treatment.
• But on most recent 2016 ATS guidelines NOACs become the recommended treatment and alternative is VKAs.
![Page 34: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/34.jpg)
![Page 35: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/35.jpg)
NOACs are not used
• CKD with Ccl less than 30 ml/min (apixaban & edoxaban can be used Ccl bet.15-30 ml/min with reduced dose )
• Moderate to severe hepatic impairment
• Pregnancy and lactation:
Still the use of LMWH is the standard of care in pregnant lady and VKAs can be used in lactating women
• PE with cancer :
LMWH
• Antiphospholipid syndrome :
not proved yet
![Page 36: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/36.jpg)
Duration of treatment
![Page 37: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/37.jpg)
![Page 38: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/38.jpg)
Pulmonary hypertension
![Page 39: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/39.jpg)
![Page 40: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/40.jpg)
![Page 41: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/41.jpg)
![Page 42: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/42.jpg)
Evaluation of patients with pulmonary hypertension
![Page 43: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/43.jpg)
![Page 44: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/44.jpg)
![Page 45: Pulmonary Embolism /Pulmonary hypertension …...PE Introduction Source of emboli Pathogenesis & Risk factors S&S Management approach: - Assess clinical probability -Assess risk of](https://reader036.vdocuments.net/reader036/viewer/2022070705/5e93c65a32af5427760b261b/html5/thumbnails/45.jpg)
Thank you