5. Clinical Presentation of acute PE
• Clinical Signs and Symptoms are frequently vague
, Less specific and rarely “classic”
• Untreated mortality rate of 20% - 30%, reduce to
5% with timely intervention
Eur Heart J 2000; 21: 130-6
6. ESC Guidelines, 2008
Clinical Presentation Suspected Acute PE
• The Classic Triad to Suspected acute PE :
• Dyspnea
• Pleuritic pain or chest pain
• Hemoptysis
Occurs in less than 20% of patients with documented acute PE
7. How to increase clinical validity
if clinical acute PE less specific ?
Should be used Well’s Score
• Low probability category : 10% of acute PE
• Intermediate probability category: 30% of acute PE
• High probability category : 65% of acute PE
Just be applicated in Normotensive PE
Ann Intem
Med, 2006;
12. Diagnosis Suspected of PE
Clinical Presentations
ECG
X photo Thorax
+
Hemodynamic State :
• Normotensive Suspected non-high risk acute PE
• Hypotensive Suspected high risk acute PE
13. Clinical Suspected high-risk PE
i.e with shock or hypotension
CT immediately available
Echocardiography
PE-specific
Fibrinolytic
or embolectomy
Search for the other causes
Fibrinolytic /embolectomy
not justified
Normal
Abnormal
No other tests available
or patient unstable
CT available and
patient stabilized
RV overload
Search for the other causes
No Yes
No Yes CTA
ESC Guidelines, 2008
14. Clinical Suspected non-high-risk PE
i.e Normotensive
Well’s Score
No PE
No treatment or
Investigate further
PE
Anticoagulant
Treatment
500 mg/L
PE
Anticoagulant
Treatment
< 500 mg/L
No Treatment
D-dimer
Low / intermediate
probability
High probability
No PE
No Treatment
CTA
ESC Guidelines, 2008
CTA
16. Pretest Probability of Wells Score
ESC Guidelines, 2008
Variables Points
Previous acute DVT or PE
Recent surgery or immobilization
Cancer
+1.5
+1.5
+1
Haemoptysis +1
Heart Rate >100 beats/min
Clinical signs of DVT
+1.5
+3
Alternative diagnosis less likely than
PE
- 3
Low
Intermediate
High
0 -1
2 -6
7
PE unlikely
PE likely
0 - 4
> 4
20. D-dimer Test
Fibrin split product
Circulating half-life of 4-6 hours
Positive Value : ≥ 500 mg/dl(PE), ≥ 900 mg/dl(DVT) has many
False Positives .
Negative Value : < 500 mg/dl(PE),<900mg/dl(DVT) has a high and
93-100% negative predictive value ( 93 – 100 % ) to rule out acute
PE
False Positives:
VTE
Pregnant Patients Post-partum < 1 week
Malignancy Surgery within 1 week
Advanced age > 80 years Sepsis
Hemmorrhage CVA
AMI Collagen Vascular Diseases
Hepatic Impairment
30. The aim of Blood Test
1. Blood Gas Analysis – Follow Up Clinical Progress in Hospitalized
2. Thrombophilia testing - How long anticoagulant to be given ?
Indication to screening test : History of unexplained or rcurrent
thrombosis and /or pregnancy complication.
Test Include :
ACAIgG ,ACAIgM, Protein S & C, AT III, APC, Fibrinogen, Homo-
cystein,CRP, Factor VIII.
Thrombophilia proven Long life anticoagulant maintenance
Thrombophilia unproven 3- 12 bulanantcoagulant maintenance
32. Anticoagulants for Acute PE
TYPES THERAPEUTIC DOSE RECOMMENDATION Grade of
Evidence
Unfractionated
Heparin
- Bolus 5000 Unit per IV
- maintain 1000 U/hr per drip
- aPTT target 2-3 times of unl
- given for 5 days
Non-high risk PE 1 A
Enoxaparin -1 mg/kg every 12 hours
- given for 5 days
Non-high risk PE
LMWH over UFH
1 A
Fondaparinux - 5 mg / 24 hr for <50 kg weight
- 7.5 mg/24 hr for 50-100 kg wght
- 10 mg / 24 hr for >100 kg weight
- given for 5 days
Non-high risk PE Indefinite
Warfarin /
Coumadin
- 2-10 mg/day
- INR target 2.5-3
- given overlapping in 3rd day
during UHF/Enoxa/Fonda
Usual
maintenance
1 A
Am J Med, 2007; 120: 18-25
33. Fibrinolytic for Acute PE
TYPES THERAPEUTIC DOSE RECOMMENDATION Grade of
Evidence
Streptokinase - Bolus 250.000 U/IV for 30
minutes
- Maintain 100.000 U/hr for
24 hours
High risk PE 1 C
Urokinase - Bolus 4400 U/kg for 10 mnt
- Maintain 2000 U/kg/hr for
12 hours
High risk PE 1 C
tPA 100 mg IV over 2 hours High risk PE 1 C
Note: No evidence catheter-directed method (local) has greater benefit than
systemic intravenous
Am J Med, 2007; 120: 18-25
34. Embolectomy for Acute PE
TYPES RECOMMENDATION Grade of
Evidence
Mechanical
percutaneous
embolectomy (MPE)
High risk PE who are unable to receive
fibrinolytic therapy
2 C
Note:
- Grade 1: Strong recommendation
- Grade 2: Weaker recommendation
- Level of evidence A: RCTs with consistent result
- Level of evidence B: RCTs with inconsistent result
- Level of evidence C: Observational studies
Am J Med, 2007; 120: 18-25
36. Mrs. AN, 37 y.o
• Dyspnea, 1 bed pillow, couging up blood
since 3 days ago.
• Left leg swelling then massaged about 6
days earlier and diagnosed DVT by doctor
• Denied Asthma, TBC and heart disease
• C M, JVP stable,TD 120/80 mmHg.HR 105 x
/mnt
Lung : Wheezing & Rales (-)
Left Leg: Edema & Warm .
Os ke RS
- ECG : Sinus Tachycardi
- Thorax Photo : WNL
,
WD/ Suspect Low Risk PE
What Next ?
Well’s Score
37. Pretest Probability of Wells Score
Variables Points
Previous acute DVT or PE
Recent surgery or immobilization
Cancer
+1.5
+1.5
+1
Haemoptysis +1
Heart Rate >100 beats/min
Clinical signs of DVT
+1.5
+3
Alternative diagnosis less likely than
PE
- 3
Low
Intermediate
High
0 -1
2 -6
7
PE unlikely
PE likely
0 - 4
> 4
Points
+1.5
-
-
+1
+1.5
+3
-
7 High
PE Likely
38. Suspect Low Risk PE
Well Score , High Probability
What Next ?
CTA
41. Background
DVT is common but elusive illness
In 1644, Schenk
In 1846,Virchow
The worldwide incidence 100 cases per 100,000 person,
annually
The incidence in Asians is 2.2 - 62.5 %
42. Complication of DVT
1. Pulmonary Embolism is the cause of death in 0.9 %
2. Post Thrombotic Syndrome 60 - 85 %
( Venous Hypertension Venous Reflux - CVI )
3. Phlegmasia Cerulea Dolens 1 – 6 %
43. The Surgical risk of Deep Vein Thrombosis
• 16 - 30 % in general surgical
• 45 - 70 % in orthopedic surgery
• 7 - 45 % in gynecologic surgery
• 25 % in urologic surgery
52. Wells Score
Clincal Features Score
- Active cancer 1
- Paralysis, recent plaster cast 1
- Recent immobilisation or surgery 1
- Tenderness along entire deep vein system 1
- Swelling of entire leg 1
- > 3 cm difference in calf circumference compared
with other leg 1
- Pitting oedema 1
- Collateral superficial veins (non Varicose) 1
- Alternative diagnosis as likely as DVT -2
High probability > 3
Moderate probability 1-2
Low Probability < 1 Interobserver reliability kappa 0.85
The prevalence of disease in each pre-test category was 85,33 and 5 % for the
high, moderate,and low probability groups, respectively.
Wells PS et al.
Lancet 1997 ; 350 : 1795-8
56. Anticoagulants for Acute DVT
TYPES THERAPEUTIC DOSE RECOMMENDATION Grade of
Evidence
Unfractionated
Heparin
- Bolus 5000 Unit per IV
- maintain 1000 U/hr per drip
- aPTT target 2-3 times of unl
- given for 5 days
- Proximal
- Distal with
severe risK
1 A
Enoxaparin -1 mg/kg every 12 hours
- given for 5 days
- Proximal
- Distal with
severe risK
1 A
Fondaparinux - 5 mg / 24 hr for <50 kg weight
- 7.5 mg/24 hr for 50-100 kg wght
- 10 mg / 24 hr for >100 kg weight
- given for 5 days
-Proximal
- Distal with
severe risK
1 A
Warfarin / - 2-10 mg/day Usual 1 A
57. Fibrinolytic for Acute DVT
TYPES THERAPEUTIC DOSE RECOMMENDATION Grade of
Evidence
Streptokinase - Bolus 250.000 U/IV for 30
minutes
- Maintain 100.000 U/hr for
24 hours
Ilio Femoral 1 C
Urokinase - Bolus 4400 U/kg for 10 mnt
- Maintain 2000 U/kg/hr for
12 hours
Iliofemoral 1 C
tPA 100 mg IV over 2 hours iliofemoral 1 C
Note: No evidence catheter-directed method (local) has greater benefit than
systemic intravenous
Am J Med, 2007; 120: 18-25
58. Thrombolytic Treatment
Illiofemoral DVT < 14 days
Percutaneus intervention is Performed in Catheter laboratory.
Technique :
- Popliteal vein is accessed by ultrasound guidance
- 5 Fr multisidehole catheter and wire is placed Thrombus obstruc.
- urokinase 80,000 IU / hr ( side arm ) + 80,000 /hr ( multisidehole)
- Infusion heparin following bolus 5,000 IU.
Evaluation by Contras Catheter after overnight .
.
59. Temporary Vena Cava Filter (VCF)
Indication : - DVT + Recurrent Pulmonary Embolism despite adequate
anticoagulation
- Contraindication for anticoagulant in Proximal DVT
progress to illiac vein
- After pulmonary embolectomy
- Floating Thrombus in inferior vena cava
VCF Performed in Catheter laboratory
61. Mr. An 60 Yo
- Right leg swelling, pain and warm
continuously causing difficult to walk since
5 days ago.
- 6 days ago he’s just returned from America
by plane for 24 hours and sleep soundly due
to drinking tranquilizers.
- Denied limb trauma history
62. Mr.An 60 Yo
- Sweeling on right thigh to calf, pitting
edema with diameter 4,5 cm greater thanleft
leg, felt warm and reddish.
- Homans’ Sign positive
Wells’ Score
What next???
WD/Suspect DVT
63.
64. Wells Score
Clincal Features Score Score
- Active cancer 1
- Paralysis, recent plaster cast 1
- Recent immobilisation or surgery 1
- Tenderness along entire deep vein system 1
- Swelling of entire leg 1
- > 3 cm difference in calf circumference compared
with other leg 1
- Pitting oedema 1
- Collateral superficial veins 1
- Alternative diagnosis as likely as DVT -2
High probability > 3
Moderate probability 1-2
Low Probability < 0 Interobserver reliability kappa 0.85
The prevalence of disease in each pre-test category was 85,33 and 5 % for the
high, moderate,and low probability groups, respectively.
Wells PS et al.
Lancet 1997 ; 350 : 1795-8
-
-
1
-
1
1
1
-
4
-
65. Mr.An 60 yo
High probability
Wells’ Score
What next
WD/Suspect DVT
What next
Ultrasound
