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Acute management of PE and ThrombolysisRCP Acute Medicine Conference
Simon Bax
Consultant Chest Physician
SASH
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Whatrsquos new in the world of PE
NCEPOD ndash Key findings
One delay or more in management was present in 383 of encounters
An avoidable delay in commencing treatment was found in 187
PE Severity assessment was not performed in 903
Wide variation in patient selection for ambulatory pathways
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Diagnostic algorithm in patients with suspected PE
NICE recommend use of the two level Wells score
What proportion have a PE
~30~12
Age-adjusted D-dimer
bull The specificity of D-dimer decreases with age
bull A multinational prospective study evaluated a previously validated age-adjusted cut-off
bull (age x 10 microgramsL in gt50s)
bull 3346 patients (PE prevalence 19)
bull Patients with a normal age adjusted D-dimer did not undergo imaging
bull Use of the age adjusted D-dimer increased the number of patients where PE could be safely excluded from 64 to 30
Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism the ADJUST-PE studyRighin et al JAMA 2014 Mar 19 311 (11) 1117-24
Case 1
bull 52 Female presented by blue light
bull Collapse while walking with shopping
bull Bipolar Obesity Smoker
bull BP ndash 8842 HR 122 RR 30 O2 88 (15LO2)
bull GCS ndash E2 V4 M5 ndash 11
PEA Arrest
bull Adrenaline
bull Alteplase 50mg bolus
bull Intubated and Ventilated
bull Lost output a further 4 times until instigated on Adrenaline infusion
bull ITU ndash Persistent high inotrope requirement despite thrombolysis
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Factors causing haemo-dynamic collapse
2019 ESC ERS Guidelines for the diagnosis and management if acute PE
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Whatrsquos new in the world of PE
NCEPOD ndash Key findings
One delay or more in management was present in 383 of encounters
An avoidable delay in commencing treatment was found in 187
PE Severity assessment was not performed in 903
Wide variation in patient selection for ambulatory pathways
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Diagnostic algorithm in patients with suspected PE
NICE recommend use of the two level Wells score
What proportion have a PE
~30~12
Age-adjusted D-dimer
bull The specificity of D-dimer decreases with age
bull A multinational prospective study evaluated a previously validated age-adjusted cut-off
bull (age x 10 microgramsL in gt50s)
bull 3346 patients (PE prevalence 19)
bull Patients with a normal age adjusted D-dimer did not undergo imaging
bull Use of the age adjusted D-dimer increased the number of patients where PE could be safely excluded from 64 to 30
Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism the ADJUST-PE studyRighin et al JAMA 2014 Mar 19 311 (11) 1117-24
Case 1
bull 52 Female presented by blue light
bull Collapse while walking with shopping
bull Bipolar Obesity Smoker
bull BP ndash 8842 HR 122 RR 30 O2 88 (15LO2)
bull GCS ndash E2 V4 M5 ndash 11
PEA Arrest
bull Adrenaline
bull Alteplase 50mg bolus
bull Intubated and Ventilated
bull Lost output a further 4 times until instigated on Adrenaline infusion
bull ITU ndash Persistent high inotrope requirement despite thrombolysis
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Factors causing haemo-dynamic collapse
2019 ESC ERS Guidelines for the diagnosis and management if acute PE
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Whatrsquos new in the world of PE
NCEPOD ndash Key findings
One delay or more in management was present in 383 of encounters
An avoidable delay in commencing treatment was found in 187
PE Severity assessment was not performed in 903
Wide variation in patient selection for ambulatory pathways
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Diagnostic algorithm in patients with suspected PE
NICE recommend use of the two level Wells score
What proportion have a PE
~30~12
Age-adjusted D-dimer
bull The specificity of D-dimer decreases with age
bull A multinational prospective study evaluated a previously validated age-adjusted cut-off
bull (age x 10 microgramsL in gt50s)
bull 3346 patients (PE prevalence 19)
bull Patients with a normal age adjusted D-dimer did not undergo imaging
bull Use of the age adjusted D-dimer increased the number of patients where PE could be safely excluded from 64 to 30
Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism the ADJUST-PE studyRighin et al JAMA 2014 Mar 19 311 (11) 1117-24
Case 1
bull 52 Female presented by blue light
bull Collapse while walking with shopping
bull Bipolar Obesity Smoker
bull BP ndash 8842 HR 122 RR 30 O2 88 (15LO2)
bull GCS ndash E2 V4 M5 ndash 11
PEA Arrest
bull Adrenaline
bull Alteplase 50mg bolus
bull Intubated and Ventilated
bull Lost output a further 4 times until instigated on Adrenaline infusion
bull ITU ndash Persistent high inotrope requirement despite thrombolysis
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Factors causing haemo-dynamic collapse
2019 ESC ERS Guidelines for the diagnosis and management if acute PE
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
NCEPOD ndash Key findings
One delay or more in management was present in 383 of encounters
An avoidable delay in commencing treatment was found in 187
PE Severity assessment was not performed in 903
Wide variation in patient selection for ambulatory pathways
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Diagnostic algorithm in patients with suspected PE
NICE recommend use of the two level Wells score
What proportion have a PE
~30~12
Age-adjusted D-dimer
bull The specificity of D-dimer decreases with age
bull A multinational prospective study evaluated a previously validated age-adjusted cut-off
bull (age x 10 microgramsL in gt50s)
bull 3346 patients (PE prevalence 19)
bull Patients with a normal age adjusted D-dimer did not undergo imaging
bull Use of the age adjusted D-dimer increased the number of patients where PE could be safely excluded from 64 to 30
Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism the ADJUST-PE studyRighin et al JAMA 2014 Mar 19 311 (11) 1117-24
Case 1
bull 52 Female presented by blue light
bull Collapse while walking with shopping
bull Bipolar Obesity Smoker
bull BP ndash 8842 HR 122 RR 30 O2 88 (15LO2)
bull GCS ndash E2 V4 M5 ndash 11
PEA Arrest
bull Adrenaline
bull Alteplase 50mg bolus
bull Intubated and Ventilated
bull Lost output a further 4 times until instigated on Adrenaline infusion
bull ITU ndash Persistent high inotrope requirement despite thrombolysis
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Factors causing haemo-dynamic collapse
2019 ESC ERS Guidelines for the diagnosis and management if acute PE
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Diagnostic algorithm in patients with suspected PE
NICE recommend use of the two level Wells score
What proportion have a PE
~30~12
Age-adjusted D-dimer
bull The specificity of D-dimer decreases with age
bull A multinational prospective study evaluated a previously validated age-adjusted cut-off
bull (age x 10 microgramsL in gt50s)
bull 3346 patients (PE prevalence 19)
bull Patients with a normal age adjusted D-dimer did not undergo imaging
bull Use of the age adjusted D-dimer increased the number of patients where PE could be safely excluded from 64 to 30
Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism the ADJUST-PE studyRighin et al JAMA 2014 Mar 19 311 (11) 1117-24
Case 1
bull 52 Female presented by blue light
bull Collapse while walking with shopping
bull Bipolar Obesity Smoker
bull BP ndash 8842 HR 122 RR 30 O2 88 (15LO2)
bull GCS ndash E2 V4 M5 ndash 11
PEA Arrest
bull Adrenaline
bull Alteplase 50mg bolus
bull Intubated and Ventilated
bull Lost output a further 4 times until instigated on Adrenaline infusion
bull ITU ndash Persistent high inotrope requirement despite thrombolysis
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Factors causing haemo-dynamic collapse
2019 ESC ERS Guidelines for the diagnosis and management if acute PE
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Diagnostic algorithm in patients with suspected PE
NICE recommend use of the two level Wells score
What proportion have a PE
~30~12
Age-adjusted D-dimer
bull The specificity of D-dimer decreases with age
bull A multinational prospective study evaluated a previously validated age-adjusted cut-off
bull (age x 10 microgramsL in gt50s)
bull 3346 patients (PE prevalence 19)
bull Patients with a normal age adjusted D-dimer did not undergo imaging
bull Use of the age adjusted D-dimer increased the number of patients where PE could be safely excluded from 64 to 30
Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism the ADJUST-PE studyRighin et al JAMA 2014 Mar 19 311 (11) 1117-24
Case 1
bull 52 Female presented by blue light
bull Collapse while walking with shopping
bull Bipolar Obesity Smoker
bull BP ndash 8842 HR 122 RR 30 O2 88 (15LO2)
bull GCS ndash E2 V4 M5 ndash 11
PEA Arrest
bull Adrenaline
bull Alteplase 50mg bolus
bull Intubated and Ventilated
bull Lost output a further 4 times until instigated on Adrenaline infusion
bull ITU ndash Persistent high inotrope requirement despite thrombolysis
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Factors causing haemo-dynamic collapse
2019 ESC ERS Guidelines for the diagnosis and management if acute PE
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
NICE recommend use of the two level Wells score
What proportion have a PE
~30~12
Age-adjusted D-dimer
bull The specificity of D-dimer decreases with age
bull A multinational prospective study evaluated a previously validated age-adjusted cut-off
bull (age x 10 microgramsL in gt50s)
bull 3346 patients (PE prevalence 19)
bull Patients with a normal age adjusted D-dimer did not undergo imaging
bull Use of the age adjusted D-dimer increased the number of patients where PE could be safely excluded from 64 to 30
Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism the ADJUST-PE studyRighin et al JAMA 2014 Mar 19 311 (11) 1117-24
Case 1
bull 52 Female presented by blue light
bull Collapse while walking with shopping
bull Bipolar Obesity Smoker
bull BP ndash 8842 HR 122 RR 30 O2 88 (15LO2)
bull GCS ndash E2 V4 M5 ndash 11
PEA Arrest
bull Adrenaline
bull Alteplase 50mg bolus
bull Intubated and Ventilated
bull Lost output a further 4 times until instigated on Adrenaline infusion
bull ITU ndash Persistent high inotrope requirement despite thrombolysis
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Factors causing haemo-dynamic collapse
2019 ESC ERS Guidelines for the diagnosis and management if acute PE
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Age-adjusted D-dimer
bull The specificity of D-dimer decreases with age
bull A multinational prospective study evaluated a previously validated age-adjusted cut-off
bull (age x 10 microgramsL in gt50s)
bull 3346 patients (PE prevalence 19)
bull Patients with a normal age adjusted D-dimer did not undergo imaging
bull Use of the age adjusted D-dimer increased the number of patients where PE could be safely excluded from 64 to 30
Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism the ADJUST-PE studyRighin et al JAMA 2014 Mar 19 311 (11) 1117-24
Case 1
bull 52 Female presented by blue light
bull Collapse while walking with shopping
bull Bipolar Obesity Smoker
bull BP ndash 8842 HR 122 RR 30 O2 88 (15LO2)
bull GCS ndash E2 V4 M5 ndash 11
PEA Arrest
bull Adrenaline
bull Alteplase 50mg bolus
bull Intubated and Ventilated
bull Lost output a further 4 times until instigated on Adrenaline infusion
bull ITU ndash Persistent high inotrope requirement despite thrombolysis
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Factors causing haemo-dynamic collapse
2019 ESC ERS Guidelines for the diagnosis and management if acute PE
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Case 1
bull 52 Female presented by blue light
bull Collapse while walking with shopping
bull Bipolar Obesity Smoker
bull BP ndash 8842 HR 122 RR 30 O2 88 (15LO2)
bull GCS ndash E2 V4 M5 ndash 11
PEA Arrest
bull Adrenaline
bull Alteplase 50mg bolus
bull Intubated and Ventilated
bull Lost output a further 4 times until instigated on Adrenaline infusion
bull ITU ndash Persistent high inotrope requirement despite thrombolysis
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Factors causing haemo-dynamic collapse
2019 ESC ERS Guidelines for the diagnosis and management if acute PE
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
PEA Arrest
bull Adrenaline
bull Alteplase 50mg bolus
bull Intubated and Ventilated
bull Lost output a further 4 times until instigated on Adrenaline infusion
bull ITU ndash Persistent high inotrope requirement despite thrombolysis
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Factors causing haemo-dynamic collapse
2019 ESC ERS Guidelines for the diagnosis and management if acute PE
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Factors causing haemo-dynamic collapse
2019 ESC ERS Guidelines for the diagnosis and management if acute PE
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Factors causing haemo-dynamic collapse
2019 ESC ERS Guidelines for the diagnosis and management if acute PE
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Massive PE ndash Acute high risk
PE
Need for CPR
bull Systolic BPlt90mmHg or systolic ge40mmHg lasting more than 15 minutes in absence of other cause
Persistent hypotension
bull Systolic BP (lt90mmHg) or vasopressors
bull And
bull End-organ hypoperfusion
bull Confusion Increased lactate Cold and clammy
Obstructive Shock
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism A Randomized Controlled Trial
bull 8 patients
bull 4 received heparin alone
bull 4 received heparin and streptokinase
bull Heparin group all died
bull Streptokinase group all survived
Jerjes-Sanchez et al J Thomb Thrombolysis 1995 2 (3)227-229
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Risk stratification in all patients with PE ndash PESI sPESI
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
RV Dysfunction
bull RV dysfunction means the presence of at least 1 of the following
ndash RV dilation (apical 4-chamber RV diameter divided by LV diameter gt09) or RV systolic dysfunction on echocardiography
ndash RV dilation (4-chamber RV diameter divided by LV diameter gt09) on CT
ndash Elevation of BNP (gt90 pgmL)
ndash Elevation of N-terminal pro-BNP (gt500 pgmL) or
ndash Electrocardiographic changes (new complete or incomplete right bundle-branch block anteroseptal ST elevation or depression or anteroseptal T-wave inversion)
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Assessing RV dysfunction at CTPA
Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung DiseaseBax et al Chest 2019 Jul 24 [Epub ahead of print]
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
BNP
BNP if elevated 10 risk of early death and a 23 risk of an adverse clinical outcome2
In normotensive patients with PE the positive predictive value of elevated BNP or NT-proBNP concentrations for early mortality is low3
In a prospective multicentre cohort study that included 688 patients NT-proBNP plasma concentrations of 600 pgmL were identified as the optimal cut-off value for the identification of elevated risk4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Troponin
A meta analysis showed that elevated Troponin was associated with an increased risk of mortality (OR 52 CI 33-84)
The risk remained in those who were haemodynamically stable (OR 59 CI 27-130)5
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Lactate
Serum lactate gt 2 associated with a higher risk of adverse outcome
The combination of RV dysfunction elevated troponin and increased lactate predicted a 66 fold of adverse short term PE related adverse events6
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Clinical laboratory and echo parameters predicting 30-day PE-related mortality in normotensive patients (adapted from Jimenez et al)
Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolismJimenez et al Thorax 2011 Jan66(1)75-81
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Classification of patients with acute PE based on early mortality risk
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Case 2
bull 80 Male Severe breathlessness
bull Collapsed the previous night
bull Very minor Left sided chest pain
bull Exercise tolerance 5-10m
bull BP 13577 HR 115
bull O2 ndash 92 ra RR 22
Prognosticationbull sPESI ndash 3 (109)bull PESI ndash 140 (10-24)bull Troponin (+ive) 63bull Echo ndash Septum deviation
D shaped LV Dilated RV PASP ndash 70mmHg
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Management
bull LMWH
bull Thrombolysis discussed (Pietho)
bull Good improvement ndash Ex tolerance improved
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Day of discharge
bull Collapseshellipagain
bull BP- 9576 HR 120 O₂ 95
bull ldquoIrsquom finerdquo
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Pre and post thrombolysis
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Pulmonary Embolism Thrombolysis trial (PEITHO)
bull 1006 patients multi-centre double blind placebo controlled
bull Randomized to receive a single dose of tenecteplase plus heparin or to receive placebo plus heparin
bull Onset of symptoms 15 days or less before randomization
bull Right ventricular dysfunction (echo ct) and positive trop
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Pulmonary Embolism Thrombolysis trial (PEITHO)
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Pulmonary Embolism Thrombolysis trial (PEITHO)
Primary outcomes
bull Death or hemodynamic de-compensation within 7 days after randomization
Safety outcomes
bull Extra-cranial major bleeding within 7 days after randomization
bull Ischemic or hemorrhagic stroke within 7 days
bull Serious adverse events within 30 days
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Results
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Safety
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Compromise
Fibrinolysis for Patients with Intermediate-Risk Pulmonary EmbolismMeyer et al N Engl J Med 2014 370 1402-1411
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Approach to Thrombolysis in intermediate high risk
bull RISK STRATIFY - PESIbull Check Trop BNP and review CT for signs of R heart
strainbull Intermediate high risk patients should be in a high
visibility environment with Thrombolytics to hand and frequently re-evaluate
bull Consider thrombolysisndash Clinical worseningndash DVT presentndash Increasing Lactatendash RA thrombusndash lt75 years of age with no prior cerebrovascular disease
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
How to dose in Thrombolysis
bull High risk
ndash Alteplase
ndash 10mg over 1-2 minutes
ndash 90mg over 2 hours (If over 65Kg)
ndash Total dose 15mgKg if lt65Kg
bull In cardiac arrest
ndash 50mg bolus ndash continue resuscitation for 30minutes to one hour
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
What risks should you quote if taking about thrombolysis
Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality Major Bleeding and Intracranial Haemorrhage A Meta-analysisChatterjee et al JACC 2014311 (23) 2414-2421
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score
bull Retrospective evaluation of 9703 patients thrombolysed between 2003 ndash 2012 ndash Clinical risk score with validation
bull Peripheral vascular disease (1 point)bull Age gt 65 (1 point)bull Prior hx of MI (1 point)bull CVA with residual deficit (5 points)
bull Score of 0 (12)bull Score of 1 (19)bull Score of 2 (24)bull Score ge 5 (178)
bull C-statistic only 066 (060-072)
Chatterjee S Thromb Haemost 2017 Jan 26 117(2) 246-251
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Topics
bull Whatrsquos new in the world of PE
bull Is this a PE
bull Front door management in suspected massive PE
bull Can I predict which patients with PE are at a high risk of early deterioration
bull Should I thrombolyse to prevent future morbidity
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
Impact of Thrombolytic Therapy on the Long-Term Outcome ofIntermediate-Risk Pulmonary Embolism
J Am Coll Cardiol 2017691536ndash4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4
References
bull 1 Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis Lancet 2012 May 12379(9828)1835-46 Epub 2012 Apr 10
bull 2 Klok FA Mos IC Huisman MV Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism a systematic review and meta-analysis Am J Respir Crit Care Med 2008178(4)425ndash430
bull 3 Kucher N Goldhaber SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism Circulation 2003108(18)2191ndash2194
bull 4 Lankeit M Jimenez D Kostrubiec M Dellas C Kuhnert K Hasenfuss G Pruszczyk P Konstantinides S Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism Eur Respir J 201443(6)1669ndash1677
bull 5 Becattini C Vedovati MC Agnelli G Prognostic value of troponins in acute pulmonary embolism a meta-analysis Circulation 2007116427433
bull 6 Short term clinical outcome of normotensive patients with acute pe and high plasma lactate Simone Vanni Thorax April 2015 Volume 70 issue 4