Thrombolysis in PE. Outline. Disclosure. Overview on Pulmonary Embolism. Hot Topics in Emergency Medicine 2012 Midyear Clinical Meeting

Transcription

1 Disclosure Thrombolysis in PE Daniel P. Hays, PharmD, BCPS, FASHP reports no relevant financial relationships. Daniel P. Hays, PharmD, BCPS, FASHP Outline 55 YOF presents to ED with SOB PMH of DVT + noncompliance of medications Witnessed PEA arrest Compressions Started 5 H s Hypovolemia, hypoxemia, hypo/hyper kalemia, H +, Hypo Glycemia, Hypo/Hyper Thermia 5 T s Tension pneumo, Tamponade, THROMBOSIS, Trauma, Tablets Overview on pulmonary embolism Strategies of management Thrombolytic therapy Recommendation Summary Overview on Pulmonary Embolism Obstruction of the PA or one of its branches by material (e.g., thrombus, tumor, air, or fat) Acute life-threatening but potentially reversible right ventricular failure. Incidence , 30% mortality. 2-8% mortality with thrombolytic therapy 65 to 90 % of (PE) arise from thrombi in the deep venous system of the lower extremities. Right heart or the pelvic, renal, or upper extremity veins Page 1 of 8

2 Risk Factors British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Thorax 2003;58: Classification Acute versus Chronic Massive or Submassive 30% of PE occurs with NO predisposing factors (unprovoked or idiopathic PE) Massive PE 5% Thrombus occluding >50% of the pulmonary vasculature Hypotension SBP <90 mmhg or a drop in SBP of 40 mmhg of baseline for period >15 min. Neck vein distension due to elevated central venous pressure. Respiratory Distress Submassive PE 24-40% Normal hemodynamics Signs & symptoms of RV dysfunction Saddle PE Page 2 of 8

3 American Journal of Emergency Medicine (2007) 27, Fibrinolytic therapy in pulmonary embolism: an evidence-based treatment algorithm Brian T. Fengler MD, William J. Brady MD Presentation SYMPTOMS Extremely variable Non-specific clinical presentation Both signs & symptoms had low sensitivity and specificity Dyspnea at rest or with exertion (73 %), Pleuritic pain (44 %) Cough (34 %) Calf or thigh pain (44 %) Calf or thigh swelling (41 %) Wheezing (21 %) Hemoptysis ( 23%) SIGNS Tachypnea (54 %) Tachycardia HR > 100/min (30 %) Crackles (51 %) Fever New Right sided heart failure Loud P2 and or right sided gallop Jugular venous distension (14 %) Multidetector Computed Tomography for Acute Pulmonary Embolism.New England Journal of Medicine. 354(22): , June 1, Page 3 of 8

4 Clinical Assessment Of Pretest Probability Of Pulmonary Embolism Well s score The revised Geneva score European Heart Journal (2008) 29, Risk Stratification Optimal diagnostic strategy and initial management Clinical markers RV dysfunction markers Cardiac injury markers Pulmonary Embolism: Remember That Patient You Saw Last Night? EMERGENCY MEDICINE PRACTICE June 2004 Volume 6, Number 6 European Heart Journal (2008) 29, European Heart Journal (2008) 29, Page 4 of 8

5 Management Modalities of Management Prevent propagation of the clot Prevent recurrent VTE Pulmonary hypertension Anticoagulation therapy Vena cava filters Thrombolytic therapy Embolectomy Thrombolytic Therapy Rapid clot lysis improvement in pulmonary perfusion & cardiovascular function Eliminates venous thrombi Controversial.!!! Harm versus Benefit Reducing risk of recurrent PE May prevent chronic vascular obstruction and persistent pulmonary HTN American Journal of Emergency Medicine (2007) 27, Fibrinolytic therapy in pulmonary embolism: an evidencebased treatment algorithm Brian T. Fengler MD, William J. Brady MD V Page 5 of 8

6 Despite the lack of mortality benefit associated with thrombolytic therapy among pt with massive PE, still it is indication for thrombolysis because successful therapy can be lifesaving. Indication Contraindications Massive PE Cardiac arrest in patient with suspected PE Severe hypoxemia Large perfusion defect on V/Q Scan Extensive embolic burden CT Submissive PE with RV dysfunction Free-floating right atrial or ventricular thrombus Patent foramen ovale Approved Thrombolytic Agents Streptokinase: May cause Hypotension Urokinase rtpa Plasminogen Activator Italian Multicenter Study 2: 100 mg (rtpa) 12% decrease in vascular obstruction at the end of the 2 h infusion period. The USPE Trial : equal efficacy of urokinase and streptokinase infused over a period of h. Page 6 of 8

7 Recommendations rtpa regimens showed better pulmonary flow at 2 hours but not subsequently compared with long and short regimens using the other agents Superiority of any thrombolytic agent or regimen over the others has not been definitively established What Did We Do? Bolus rtpa Immediately ROSC Patient went to MICU D/C home within 7 days Summary References The use of thrombolytic therapy in PE is still controversial. Perform risk stratification on all patients If indicated, DO NOT DELAY thrombolysis Beware of possible complications (pray for no bleed) Evidence has failed to prove any deference between deferent types of thrombolytic agents European Heart Journal (2008) Guidelines on the diagnosis and management of acute pulmonary embolism. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. American Journal of Emergency Medicine Fibrinolytic therapy in pulmonary embolism: an evidence-based treatment algorithm Brian T. Fengler MD, William J. Brady MD. Uptodate Chest vol 135 Issue 5 May 2009 Thrombolytic Therapy for Acute Pulmonary Embolism Emergency Medicine Practice 2004 June Pulmonary Embolism: Remember That Patient You Saw Last Night? Page 7 of 8

8 Saddle PE : that lodges at the bifurcation of the main pulmonary artery Page 8 of 8