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Decision making for Pulmonary

Embolism

Michał Chyrchel MDUniversity Hospital , Krakow, Poland

Risk stratification according to expected PE –related early mortality rate

PE autopsy material

Jaff et al. Circulation 2011

PE treatment (including high risk PE)

• Respiratory and hemodynamic support

• Anticoagulation

• Trombolytic treatment

• Percutaneous intervention

• Surgical trombectomy

Anticoagulation

• Anticoagulation treatment plays a pivotal role in the management of patients with PE

• Initial anticoagulation should be introduce immediately • Potential options:

- UFH

- LMWH (dalteparin, enoxaparin, nodraparin)

- Fondaparynuks

- Riwaroksaban

- other

Anticoagulation options for Venous Thromboembolism

JAMA 2014;311(7): 717-728 Wells PS et al.

Anticoagulation

• In massive PE with hemodynamic consequences or a

shock - anticoagulation with UFH

• LMWH should be given in care in pts with renal failure

• Due to high mortality rate in untreated pts anticoagulation

should be considered when PE is strongly suspected:

awaiting for definite dgn confirmation

• Duration depends on many factors (PE etiology, transient

risk factors, cancer coexistence,etc.) BLEEDING RISK

Thrombolyitic regimens for PE• rtPA- standard: 100 mg i.v. (2 h)- fast regimen: 0,6 mg/kg (max. 50 mg) during 15 min• Streptokinase- fast regimen: 1,5 mln j.m. units i.v. (2h)- standard: 250 000 j.m. within 30 min, followed by 100 000

jm/h within 12-24 h • Urokinase- fast regimen: 3 mln j.m. i.v. within 2 h- standard: 4400 j.m./kg within 10 min, followed by 4400

j.m./h within 12-24 h

Specifity of lungs circulation

• Exquisitely sensitive to lysis

• Point of convergence of venous circulation

• Pulmonary blood flow = entire CO (Cardiac Output)

• In comparison: brain 15 % of CO, heart 5 % of CO

• Repeated „hits” of tPA by recirculation

Combined pharmacological approach

• Safe dose thrombolysis• Modified and short dose of heparin• New oral anticoagulants• 98 pts with moderate and severe PE• O mortality rate in hospital, bleeding 0 in hospital• Low adverse events in follow-up

Sharifi et al. Clin Card 10/2013

Other therapautic options for PE

• Surgical pulmonary embolectomy

• Percutaneous catheter embolectomy and fragmentation

- When contraindications for fibrynolytic therapy- Fibrynolytic therapy failed

! Only if: • applicable technical condition available • experienced interventional team

Other therapautic options for PE

Vena Cava Filters

• Ideally the retrievable variety of device

• When contraindication to anticaogaulation (eg. Recent

--- hemorrhage

• - impending surgery

Mortality spectrum in PE patients

W Kasper JACC 1997;30:1165-1171

Conclusions

• PE is common, potential live threatening condition

• In hospital mortality rate up to 12 % (US)

• Aggressive pharmacological - interventional treatment

is effective in majority of cases

• Farther diagnosis of possible PE causes is mandatory

(deep vein thrombosis, cancer, other)

• Is one of more frequent comorbiditie in patients

hospitalized from other reason.