NC2011-08 PE - Dr. Schub (with narrartion)

Pulmonary embolism and DVT: 

Pulmonary embolism and DVT Herbert M Schub MD Chief, Pulmonary Division

Topics To Be Covered: 

Topics To Be Covered Diagnostic Algorithm…Well’s Score V/Q vs CT for PE How useful is D-Dimer? How useful is Doppler Ultrasound? Heparin vs Lovenox Length of Treatment When to Use IVC Filters? When to Use Thrombolytics? Hypercoagulation Workup DVT prophylaxis and methods

PULMONARY EMBOLISM: 

PULMONARY EMBOLISM Most Overdiagnosed Most Underdiagnosed WHAT TO DO????

HOW TO CONFIRM: 

HOW TO CONFIRM THE NOT-SO-GOOD OLD DAYS WACKER’S TRIAD Increase Bilirubin and LDH with normal SGOT A-a O 2 gradient increased THE CHEST X-RAY Pulm art cutoff w/ pleonemia Elevated diaphragm on same side Hampton’s Hump EKG S 1 -Q 3

HOW TO CONFIRM: 

HOW TO CONFIRM THE NOT-SO-GOOD OLD DAYS WACKER’S TRIAD Increase Bilirubin and LDH with normal SGOT A-a O 2 gradient THE CHEST X-RAY Pulm art cutoff w/ pleonemia Elevated diaphragm on same side Hampton’s Hump EKG S 1 -Q 3

ALONG CAME THE VENTILATION PERFUSION LUNG SCAN: 

ALONG CAME THE VENTILATION PERFUSION LUNG SCAN

Slide 14: 

Interpretation criteria Modified PIOPED criteria: The following modified PIOPED criteria were derived from a retrospective analysis of the PIOPED database. High Probability (≥80%, in the absence of conditions known to mimic pulmonary embolism) ≥2 large mismatched segmental perfusion defects or the arithmetic equivalent in moderate or large and moderate defects. (A large segmental defect, >75% of a segment, equals 1 segmental equivalent; a moderate defect, 25 – 75% of a segment, equals 0.5 segmental equivalents; a small defect, <25% of a segment, is not counted.) Two large mismatched segmental perfusion defects, or the arithmetic equivalent, are borderline for “high probability.” Individual readers may correctly interpret individual images with this pattern as “high probability.” In general, it is recommended that more than this degree of mismatch be present for the “high probability” category.

Interpretation Criteria: 

Interpretation Criteria Intermediate Probability (20% - 79%) One moderate to two large mismatched perfusion defects or the arithmetic equivalent in moderate or large and moderate defects. Single-matched ventilation-perfusion defect with clear chest radiograph. Very extensive matched defects can be categorized as “low probability.” Single ventilation-perfusion matches are borderline for “low probability” and thus should be categorized as “intermediate” in most circumstances by most readers, although individual readers may correctly interpret individual scintigrams with this pattern as “low probability.” Difficult to categorize as low or high or not described as low or high.

Slide 16: 

Low Probability (<20%) Nonsegmental perfusion defects (e.g. cardiomegaly, enlarged aorta, enlarged hila, elevated diaphragm). ·        Any perfusion defect with a substantially larger chest radiographic abnormality. Perfusion defects matched by ventilation abnormality provided that there are: a) clear chest radiograph; and b) some areas of normal perfusion in the lungs. Any number of small perfusion defects with a normal chest radiograph. Normal ·        No perfusion defects or perfusion exactly outlines the shape of the lungs seen on the chest radiograph (note that hilar and aortic impressions may be seen and the chest radiograph and/or ventilation study may be abnormal). The combination of the PIOPED criteria with clinical data such as risk factors for PE increases the diagnostic accuracy of the test, as shown in table 2. V/Q scan interpretation Proportion of pts with PE and 0 risk factors Proportion of pts with PE and 1 risk factor Proportion of pts with PE and 2 risk factors High82%84%97%Intermediate25%37%45%Low4%12%21%Normal0%0%0%Risk factors = immobilization for 3 days or more, surgery, trauma to the lower extremities or central venous instrumentation within 3 months of presentation. The stripe sign (activity at the periphery of a perfusion defect) lowers the chance of pulmonary embolism in the zone of the perfusion defect that shows the stripe.

V/Q vs CT: 

V/Q vs CT

D-DIMER: 

D-DIMER How Useful?

Conclusion: 

Conclusion D-Dimer level <500 ng/ml by quantitative ELISA or semi-quantitative Latex Agglutination is sufficient to exclude PE in patients with a LOW or MODERATE pretest prob of PE. A Negative D-dimer by Erythrocyte Agglutination is ONLY sufficient to exclude PE in pts with a LOW pretest prob of PE

DOPPLER ULTRASOUND: 

DOPPLER ULTRASOUND False Positive…3% False Negative..29% Consider serial exams in non hi-probability clinical, and lung scan &/or CT for PE, AND adequate cardiopulmonary reserve In One Study, fewer than 3% developed PE over a 2 week period while anti-coag- ulation was withheld IF serial ultrasounds were Negative

Topics To Be Covered: 

Topics To Be Covered Diagnostic Algorithm…Well’s Score V/Q vs CT for PE How useful is D-Dimer? How useful is Doppler Ultrasound? Heparin vs Lovenox Length of Treatment When to Use IVC Filters? When to Use Thrombolytics? Hypercoagulation Workup DVT prophylaxis and methods

Common Questions re: Treatment Acute P.E.: 

Common Questions re: Treatment Acute P.E. Should I initiate therapy? Which anticoagulant should I use? What is the appropriate dose? How should I monitor the treatment? What is the clinical evidence supporting its use? What are the common complications? For how long should I treat?

Initiation of Therapy: 

Initiation of Therapy HIGH clinical suspicion and/or P.E. confirmed Approximately 30% mortality untreated versus less than 3% risk major bleeding

Which Anticoagulant?: 

Which Anticoagulant? SC LMWH is preferred for most hemodynamically stable patients: Cf with IV UFH: lower mortality,fewer recurrent thrombotic events, and less major bleeding IV UFH when: massive PE with persistent hypotension due to PE, increased risk of bleeding, concern about subcut absorption, eg morbid obesity, thrombolysis is being consider whencreatinine clearance is less than 30 ml/mi SC UFH is acceptable

Appropriate Dose and Monitoring: 

Appropriate Dose and Monitoring LMWH: Enoxaparin sc 1 mgm/kgm ACTUAL body wght q 12 h Alternatively, 1.5 mgm/kgm qd 1 mgm/kgm q12h preferred for: patients with cancer, extensive clot burden, actual body weight between 101 and 150 kg, BMI between 30 and 40 Heparin (unfractionated) 250 units/kgm subcut every 12 hours Heparin (unfractionated) 80 units/kgm bolus, then 18 units/kgm /hour intravenously aPTT 55-85 sec q4-6h

Warfarin: 

Warfarin Can be initiated on the same day: Do NOT initiate prior to heparin… Warfarin alone assoc with 3 X incidence recurrent PE of DVT Should overlap with heparin for minimum of 5 days AND until the INR therapeutic (2.0 to 3.0) for at least 24 hours Dosing: Initiate not more than 5 mg/day for the first 2 days(smaller doses in elderly) and then adjust daily according to INR Adjust daily until stabilized for at least 1-2 weeks… then every 2-4 weeks Remember that other drugs and medical conditions(diet) can affect the INR

Complications of anticoagulation: 

Complications of anticoagulation Major Bleeding (intracranial,retroperit,life-threatening) Less than 3% with heparin…recent surg- ery,trauma,age>70,ASA, renal failure… Less with SC LMWH Warfarin….less than 3% BUT mortality with major bleed can be as high as 13% Management of Major Bleeding due to IV UFH & SC LMWH Reverse with protamine sulfate…. Anti-factor Xa only partially reversed Management of Major Bleeding Due to Coumadin Vitamin K and Fresh Frozen Plasma Heparin-Induced Thrombocytopenia(HIT) Monitor Platelets

Duration of Therapy: 

Duration of Therapy First Episode of P.E. Reversible or temporary risk factor (immobilization, surgery, trauma) Warfarin for at least 3 months Unprovoked Controversial…2008 ACCP Guidelines recommend 3 months and then reassessment Recurrent PE Indefinite warfarin

Topics To Be Covered: 

Topics To Be Covered Diagnostic Algorithm…Well’s Score V/Q vs CT for PE How useful is D-Dimer? How useful is Doppler Ultrasound? Heparin vs Lovenox Length of Treatment When to Use IVC Filters? When to Use Thrombolytics? Hypercoagulation Workup DVT prophylaxis and methods

Inferior Vena Cava Filters Indications: 

Inferior Vena Cava Filters Indications Absolute Contraindication to Therapeutic Anticoagulation Failure of Anti-Coagulation With Acute Proximal Venous Thrombosis Controversial Indications: Compromised Vascular Bed Proximal VT in pt w/ poor cardiopulm- onary Reserve Venous Thromboembolism in a pt with high risk of bleeding

Topics To Be Covered: 

Topics To Be Covered Diagnostic Algorithm…Well’s Score V/Q vs CT for PE How useful is D-Dimer? How useful is Doppler Ultrasound? Heparin vs Lovenox Length of Treatment When to Use IVC Filters? When to Use Thrombolytics? Hypercoagulation Workup DVT prophylaxis and methods

Topics To Be Covered: 

Topics To Be Covered Diagnostic Algorithm…Well’s Score V/Q vs CT for PE How useful is D-Dimer? How useful is Doppler Ultrasound? Heparin vs Lovenox Length of Treatment When to Use IVC Filters? When to Use Thrombolytics? Hypercoagulation Workup DVT prophylaxis and methods

Causes of Hypercoagulation: 

Causes of Hypercoagulation Acquired Inherited

Topics To Be Covered: 

Topics To Be Covered Diagnostic Algorithm…Well’s Score V/Q vs CT for PE How useful is D-Dimer? How useful is Doppler Ultrasound? Heparin vs Lovenox Length of Treatment When to Use IVC Filters? When to Use Thrombolytics? Hypercoagulation Workup DVT prophylaxis and methods

DVT Prophylaxis: 

DVT Prophylaxis Risk factors Criteria For a Good Agent

Pharmacologic Agents For Prevention DVT: 

Pharmacologic Agents For Prevention DVT Unfractionated vs LMW: In meta-analysis, no difference efficacy, But 72 % risk reduction in major bleeding with LMW (enoxaparin) Fondaparinux less efficacy than enoxa- parin 30 mgm BID but same efficacy as enoxaparin 40 mg qd If renal impairment, elderly,diabetes mellitus, or high risk of bleeding, decrease usual dose LMW heparin, fondaparinux, or consider unfractionated heparin and/or IPC (Intermittent Pneumatic Compression)

Pharmacologic Agents For Prevention DVT- II: 

Pharmacologic Agents For Prevention DVT- II Aspirin highly effective reducing major ARTERIAL thrombosis but 2008 ACCP guidelines recommend against use of Aspirin alone as thrombophylaxis . Warfarin not appropriate Can cause transient hypercoagulable state in first 36 hr-due to decline Prot C Ultimate anti-coagulant delayed until 36 to 72 hours after oral admin

Topics To Be Covered: 

Topics To Be Covered Diagnostic Algorithm…Well’s Score V/Q vs CT for PE How useful is D-Dimer? How useful is Doppler Ultrasound? Heparin vs Lovenox Length of Treatment When to Use IVC Filters? When to Use Thrombolytics? Hypercoagulation Workup DVT prophylaxis and methods

THANK YOU,SABA THANK YOU, SABA THANK YOU ,SABA THANK YOU,SABA THANK YOU, SABA THANK YOU, SABA THANK YOU,SABA: 

THANK YOU,SABA THANK YOU, SABA THANK YOU ,SABA THANK YOU,SABA THANK YOU, SABA THANK YOU, SABA THANK YOU,SABA

Appropriate Dose and Monitoring: 

Appropriate Dose and Monitoring LMWH: Enoxaparin sc 1 mgm/kgm ACTUAL body wght q 12 h Alternatively, 1.5 mgm/kgm qd 1 mgm/kgm q12h preferred for: patients with cancer, extensive clot burden, actual body weight between 101 and 150 kg, BMI between 30 and 40 .Tinzaparin 175 IU/kg SC QD…contraindicated: Age over70 and renal insufficiency .Dalteparin 200 IU/kg SC Qd…if pt > 90 kgm, use enoxa- parin or tinzaparin Monitoring with anti-Xa levels Warranted only in special circumstances: morbid obesity,low body weight, renal insufficiency and pregnancy Heparin (unfractionated) 250 units/kgm subcut every 12 hours Heparin (unfractionated) 80 units/kgm bolus, then 18 units/kgm /hour intravenously