Physician should have a high suspicion to diagnose patient with pulmonary Embolism, this slides will give you precise Diagnosis, Investigation and guideline directed Treatment.

1. PulmonaryEmbolism
Dr. Rohan Sonawane
MBBS, MD, DNB ( Interventional Cardiology reg)

2. • Introduction
• Definition & Sources
• Riskfactors & aetiology
• Pathogenesis
• Clinical presentation
• Differential Diagnosis
• Investigations
• Management
• Complications
• Prevention

3. • It is the third most common cardiovascular
disease after MI and stroke.
• Annual incidence of 100-200 per 1 lac
population.
• It is the only preventable lethal disease.

4. Pulmonary Embolism
• Thrombus dislodges (DVT) and travels to pulmonary
arteries causing occlusion of apulmonary artery(ies).
• Provoked PE: PE in patients with recent
occurrence of major clinical risk factor for VTE.
Like recent Sx, trauma, OCP.
• Proximal DVT: DVT in popliteal vein or above
(40%)
• Unprovoked PE: PE in patients with no recently
occurring major clinical risk factors for VTE or
patients with active cancer, thrombophilia or
family history of DVT (these are risks, but they
are constant)

5. Source
• DVT
• Intracardiac Clot
• Air embolism
• Fat embolism
• Amniotic fluid embolism
• Septic embolism
• Tumor embolism

6. Risk Factors
• Virchow’s Triad

7. Risk Factors
• Prior DVTorPE
• CongestiveHeart Failure
• Malignancy
• Obesity
• smoking
• Estrogen, OCP
,HRT
• Pregnancy
• Lower limbs injury
• Orthopedic Surgery
• Prolonged immobilization, travel
• Surgery requiring >30 minutes general anesthesia

8. Risk Factors
• Age> 40
• VenousStasis
• Factor VLeiden mutation
• Protein Cdeficiency
• Protein Sdeficiency
• Antithrombin deficiency
• Anticardiolipin antibodies
• SLE,APS
• Hyperhomocystinemia

9. Risk Factors
ICU-related factors:
• Immobility
• Neuromuscular paralysis (drug-induced)
• Central venous catheters
• Severesepsis

10. Pathogenesis

12. Clinical Presentation
• Small PE:Asymptomatic, SOB,chestdiscomfort.
• Medium PE: SOB,Haemoptysis, Pleuritic chest
pain, Tachycardia,Tachypnea, Pleural rub.
• Massive PE: Death, Shock,Severecentral chest
pain, Syncope, Pallor, Sweating, Central cyanosis,
Elevated JVP
,Loud P2,S2split, galloprhythm.
1

14. Clinical Prediction Score Clinical decision points
Wells rule Original
version1
Simplified
version2
Previous PE or DVT 1.5 1
Heart Rate ≥ 100 bpm 1.5 1
Sx or immobilisation within past 4 weeks 1.5 1
Hemoptysis 1 1
Active Cancer 1 1
Clinical Sign of DVT 3 1
Alternative Δ less likely 3 1
Clinical probability
PE unlikely 0-4 0-1
PE likely > 5 ≥2
1. Wells PS et al. Thromb Haemost 2000;83(3):416–420.
2. Gibson NS, Wells PS et al. Thromb Haemost 2008;99(1):229–234.

15. Clinical Prediction Score Clinical decision points
Revised Geneva Score Original version1 Simplified version2
Previous PE or DVT 3 1
Heart rate
75-94 bpm
≥95 bpm
3
5
1
2
Surgery or Fracture within past month 2 1
Hemoptysis 2 1
Active Cancer 2 1
Unilateral lower limb pain 3 1
Pain on deep veinous palpation/
unilateral edema
4 1
Age ≥ 65 years 1 1
Clinical probability
PE unlikely 0-5 0-2
PE likely ≥6 ≥3
1. Le Gal G et al. Ann Intern Med 2006;144(3):165–171.
2. Klok FA et al. Arch Intern Med 2008;168(19):2131–2136.

16. Differential Diagnosis
• Myocardial Infraction
• Pleurisy
• Pneumonia
• Bronchitis
• Pneumothorax
• Costochondritis
• Rib #

17. Investigations
• D-dimer
• ECG
• Chest X-ray
• Echocardiography
• Ventillation Perfusion Scan
• CT Pulmonary Angiography
• Invasive Pulmonary Angiography

18. D-dimer
• Levels elevate in acute thrombosis
• High negative predictive value and low
positive predictive value
• False positive in many conditions like in
cancer & pregnancy
• Specificity decreases with age (almost 10%
in patients > 80years)
• Age adjusted cut offs used after 50 years i.e.
(age x 10 ug/L)
• For < 50 years, cut off is 500 ug/L

19. ECG
In severe cases
1) RV strain, like inversion of T waves in leads V1–V4, a QR
pattern in V1
2) S1Q3T3 pattern
2) Incomplete or complete RBBB
In milder cases
Only anomaly may be sinus tachycardia - 40%
Atrial arrhythmias, most frequently atrial fibrillation may be seen

20. ECG

22. Westermark’ssign
Focal olegemia

23. Dilated RDPA
Palla’s Sign

24. 2D Echo
• Echo doesnot provide conclusive evidence
of PE.
• Sensitivity is only 65%
• But is available bedside and cheap.
• Rules out other causes like MI, Tamponade

28. IVC is dilated without any inspiratory collapse

29. Ventilation/PerfusionRatio
• Increases specificity
• In acute PE, ventilation is expected to be normal in hypoperfused
segments
• Radiation exposure lower than CT angiography
• Radiation and contrast medium-sparing procedure
• So can be done in :
 Outpatients with low clinical probability
 In young (particularly female) patients,
 In pregnancy
 History of contrast medium-induced anaphylaxis
 In severe renal failure
• Results are interpreted as low, intermediate or high probability of PE

30. Ventilation/Perfusion Ratio

31. CT Pulmonary Angiography
• Method of choice for imaging patients with suspected PE
• Highly sensitive and specific
• Cannot interpret subsegmental thrombus
• Radiation and Iodine contrast are major drawbacks
• Can’t be used in renal failure patients.

32. CTPulmonary Angiography

33. The PIOPED II trial observed a sensitivity of
83% and a specificity of 96% for MDCT
Negative Predictive Value
low clinical probability of PE - 96%
intermediate clinical probability - 89%
high pre-test probability - 60%
Positive Predictive Value
Low clinical probability of PE – 58%
Intermediate clinical probability – 92%
High clinical probability- 96%
PIOPED ll trail
(Prospective Investigation on Pulmonary Embolism Diagnosis)

34. PulmonaryAngiography
• Was Gold Standard for decades
• Replaced now by CT pulmonary angiography
• Often used to guide percutaneous catheter-
directed treatment of acute PE
• Procedure-related mortality 0.5%, major non-fatal
complications 1%

35. Pulmonary Angiography

36. Management of PE

37. Risk Stratification

38. Diagnostic algorithm for Non high-risk PE
[2014 ESC Guidelines. European Heart Journal (2014) 35, 3033–3080 ]

39. Diagnostic algorithm for High-risk PE
[2014 ESC Guidelines. European Heart Journal (2014) 35, 3033–3080
]

40. Pulmonary Embolism Severity Index

41. Original PESI Simplified PESI

42. Intermediate risk PE
• Hemodynamically stable with evidence of
myocardial injury and RV dysfunction with high
PESI
• They have high 30 day mortality
• Early reperfusion is required in them

44. Thrombolytic Therapy
• Primary reperfusion
• PE with hemodynamic instability
• use in stable pt is contaversial .
• Initiated within 48 hrs of symptoms can be
extend upto 6-14 days of symptoms.
• Aim to: Relievepulmonary vasculature
obstruction, Improve right ventricular
efficacy, Correct the hemodynamic
instability.
• Risk: Bleeding

45. Thrombolytic Agents

46. Anticoagulation Therapy
• Pt with PE should receive at least 3 months of
Anticoagulation treatment.
• Pt with cancer are candidate for indefinite treatment due
to high recurrence rate (20% after 12 months of index
event)
• Parentral anticoagulation should be started immediately
with thrombolysis in high/ intermediate high risk pt.
• In Low risk/ intermediate low risk PE pt oral anti-
coagulation (VKA/NOAC) to be started immediately
• VKA should be started under cover of UFH/LMWH till INR
2-3 for two consecutive day.
• Maintain INR 2-3
• Risk of bleeding: old age, GI bleed, Renal and hepatic
disease etc.

47. Parenteral AnticoagulantTherapy
UnfractionatedHeparin
• Usedforprimaryreperfusion
• Bolusdoseabout100U / kg body weight
• MaintenanceDose 12U/kgivinfusion
• Follow up byaPTT (1.5-2.0)
• Preferredincreatinineclearance
<30ml/kg/min 20/01/2016

48. LMWH
• Preferred over UFH
• Low risk of bleeding
• No need for monitoring

49. LMWH

50. OralAnticoagulantTherapy
• Warfarin
• 3-5 mg/day orally with LMWH (5 daysto start
acting)
• Duration: 3-6 months
• Monitor INR(2-3)

51. New Oral Anticoagulants
Drug Dose
Rivaroxaban
(EINSTEIN-DVT2010/PE2012)
15mg BD x 3weeks then
20mg OD
Dabigatran
(RE-COVER2009/ RE- COVER
ll 2014)
150mg twice a day (110 bd
for elderly)
Apixaban
(AMPLIFY2013)
10mg BD x 7 days then
5mg BD

52. Venacava filter
1
3

53. • IVC filter use is restricted to
1. Contraindication to anti-coagulation
2. Recurrent PE despite adequate
anticoagulation
• Retrievable IVC filters should be implanted
and removed within 3 months if possible.
• Routinely placing filters maybe harmful

54. Embolectomy
• Surgical Embolectomy
• Catheter Embolectomy
• Massive life-threatening PE

55. Prevention
• Prophylaxis is the single mostimportant
measure for ensuring patient safety in
hospitalizedpatients

56. RISK FACTOR SCORING
Cancer 3
Previous VTE 3
Immobility 3
Thrombophilia 3
Trauma/surgery 2
Age ≥ 70 years 1
Heart/respiratory failure 1
Acute MI or stroke 1
Infection/rheumatologic disorder 1
Obesity 1
Hormonal treatment 1
Padua Prediction Score for Identification of Hospitalized Patients at Risk for Venous
Thromboembolism
High risk for developing PE is defined as 4 score points or greater.

57. Condition Prophylaxis
Hospitalization with medical
illness
-Unfractionated heparin 5000 units SC bid or tid or -
-Enoxaparin 40 mg SC qd or
-Dalteparin 2500 units or 5000 units SC qd or
-Fondaparinux 2.5 mg SC qd with normal renal
function (in patients with a heparin allergy such
as heparin-induced thrombocytopenia) or
-Graduated compression stockings or intermittent
pneumatic compression for patients with
contraindications to anticoagulation
-Consider combination pharmacologic and
mechanical prophylaxis for high-risk patients
General surgery
-Unfractionated heparin 5000 units SC bid or tid or
-Enoxaparin 40 mg SC qd or
-Dalteparin 2500 or 5000 units SC qd
Major orthopedic surgery
-Warfarin (target INR 2 to 3) or Enoxaparin 30 mg
SC bid or
-Enoxaparin 40 mg SC qd or
-Dalteparin 2500 or 5000 units SC qd or
-Fondaparinux 2.5 mg SC qd or Rivaroxaban 10 mg
qd or
-Aspirin 81 mg qd or
-Dabigatran 220 mg qd (not in the U.S.) or
-Apixaban 2.5 mg twice daily (not in the U.S.) or
-intermittent pneumatic compression (with or
without pharmacologic prophylaxis)

58. Take home message
• PE is common but overlooked
• High suspicion to make diagnosis
• D- dimer, Echo, CTPA diagnostic tools
• Immediate reperfusion for high risk cases
• Give anticoagulants to all for 6 months
• Prophylaxis is important for hospitalized
patients.