pulmonary embolism criteria recent advances

1. PULMONARY EMBOLISM
Dr. Kamlesh Kumar
DM Cardiology
Consultant, Cardiology
PARAS HMRI HOSPITAL, Patna

3. VTE Is a Leading Cause of Death Worldwide
An estimated 300,000
VTE-related deaths
occur in the US
each year2
VTE is estimated to cause at least
3 million deaths a year worldwide3
1. Cohen AT et al, Thromb Haemost 2007;98:756–764; 2. Heit JA et al, Blood 2005;106:Abstract 910;
3. ISTH Steering Committee for World Thrombosis Day J Thromb Haemost 2014;12:1580–1590
VTE is estimated to cause >500,000 deaths
in Europe every year1
L.IN.MA.11.2016.0004

4. India
• The incidence of VTE was 17.46 per 10,000
admissions.
• A.D. Lee, E. Stephen, S. Agarwal, P. Premkumar* Vascular & General Surgery,
Christian Medical College, Vellore, Tamilnadu, India

5. Case study
• A 45 year old male patient,
• h/o tibia fracture on 14/04/22
• 7-days later he developed sudden onset
breathlessness
• With PR 140/min
• RR 30/min
• BP =100/70 mm Hg
• SPO2 - 92 % on room air

6. Wells’ Score
Clinical symptoms of DVT
(leg swelling, pain with
palpation)
3.0
Other diagnosis less likely
than pulmonary embolism
3.0
Heart rate >100 1.5
Immobilization (≥3 days) or
surgery in the previous four
weeks
1.5
Previous DVT/PE 1.5
Hemoptysis 1.0
Malignancy 1.0
Traditional clinical probability
assessment (Wells criteria)
High >6.0
Moderate 2.0 to 6.0
Low <2.0
Simplified clinical probability
assessment (Modified Wells criteria)
PE likely >4.0
PE unlikely ≤4.0

9. 2D-Echo

10. CT-Pulmo angio

13. = 0 Point 30-day mortality 1 %
> 1 Point 30-day mortality 10.9%

15. • Troponin I 0.78 ng/ml
• sPESI 1

17. PEITHO trial
• In normotensive patients with intermediate-risk PE,
• Presence of RV dysfunction and elevated troponin
levels,
• Thrombolytic therapy was associated with a
significant reduction in the risk of haemodynamic
decompensation or collapse.
• But an increased risk of severe extracranial and
intracranial bleeding.

18. NOACs non-inferior to Warfarin

19. Rivaroxaban 15 mg BID for 3 weeks-20 OD
Apixaban 10 BID 1 week then 5 BID
• Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M, Masiukiewicz U, Pak R, Thompson J,
Raskob GE, Weitz JI. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J
Med 2013;369:799, 808.
• Buller HR, Prins MH, Lensin AW, Decousus H, Jacobson BF, Minar E, Chlumsky J, Verhamme P, Wells
P, Agnelli G, Cohen A, Berkowitz SD, Bounameaux H, Davidson BL, Misselwitz F, Gallus AS, Raskob
GE, Schellong S, Segers A. Oral rivaroxaban for the treatment of symptomatic pulmonary
embolism. N Engl J Med 2012;366:1287,1297.

22. Duration.
• Anticoagulant for >3 months with reversible risk
factor.
• Anticoagulation for indefinite duration for
a) Not related to major reversible risk factor
b) APLA/ malignancy/ recurrent VTE.
Rivaroxaban 10 OD/ Apixaban 2.5 BID

29. Catheter-Based Thrombus Removal
In patients with acute PE associated with
hypotension and who have
(i) contraindications to thrombolysis,
(ii) failed thrombolysis, or
(iii) shock that is likely to cause death
before systemic thrombolysis can take
effect (eg, within hours),
if appropriate expertise and resources are
available, we suggest catheter-assisted
thrombus removal over no such
intervention (Grade 2C).

30. DEFINITIONS
• Provoked DVT or PE: DVT or PE in patients with recent
occurrence of major clinical risk factor for VTE
• Proximal DVT: DVT in popliteal vein or above
• Unprovoked DVT or PE: DVT or 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)
• Terminology such as “provoked” vs.
“unprovoked” PE/venous thromboembolism
(VTE) is no longer supported by the guidelines;
instead they propose using terms like “reversible
risk factor,” “any persistent risk factor,” or “no
identifiable risk factor.”

31. Vena Cava Filters for the Initial Treatment of Patients With DVT
In patients with acute DVT of the leg, we
recommend against the use of an IVC filter
in addition to anticoagulants (Grade 1B).
In patients with acute proximal DVT of
the leg and contraindication to
anticoagulation, we recommend the use
of an IVC filter (Grade 1B).

32. Risks for Recurrence
► “Unprovoked”
► Strong FH; PMH of VTE
► Antiphospholipid antibody syndrome
► Cancer
► Male (Kyrle PA. NEJM 2004; 350: 2558)
(McRae S. Lancet 2006; 368: 371-8)
► Presentation with PE Symptoms
Eichinger. Arch Intern Med 2004;164: 92)

36. Natural History of VTE
• 40-50% of pts with DVT develop PE, often “silent”
• PE presents 3-7 days after DVT
• Fatal within 1 hour after onset of respiratory symptoms
in 10%
• Shock/persistent hypotension in 5-10% (up to 50% of
patients with RV dysfunction)
• Most fatalities occur in untreated pts
• Perfusion defects completely resolve in 75% of all
patients (who survive)

37. Simplified Geneva Score
Variable Score
Age >65 1
Previous DVT or PE 1
Surgery or fracture within 1
month
1
Active malignancy 1
Unilateral lower limb pain 1
Hemoptysis 1
Pain on deep vein palpation of
lower limb and unilateral
edema
1
Heart rate 75 to 94 bpm 1
Heart rate greater than 94 bpm +1
Score of less than 2 is low probablility for PE, score of less than 2
2 plus a negative D-dimer results in a likelihood of PE of 3%

38. PULMONARY EMBOLISM
SEVERITY INDEX(PESI)
AGE >80
YEARS
1
CHF
CANCER
1
1
COPD 1
PR>110/MIN 1
SBP<90 MM
HG
1
SPO2<90% 1
HIGH RISK>/=
1
LOWRISK - =
0
Massive PE
>50% of vasculature
Sub-massive PE
25-50%
Small PE

40. Thrombophilia testing
X Do not offer to patients who are continuing
anticoagulation treatment
X Do not offer to patients who have had
provoked DVT or PE
X Do not routinely offer to first-degree relatives
of people with a history of DVT or PE and
thrombophilia
Consider for patients with unprovoked PE or
PE if it is planned to stop anticoagulation
treatment

41. BARD
RECOVERY
FILTER

42. Radiographic Signs
• Westermark
Sign
HAMPTON’s Hump

43. Presentation
 Dyspnea at rest or with
exertion (73 %)
 Pleuritic pain (44 %)
 Cough (34 %)
 >2-pillow orthopnea (28
%)
 Calf or thigh pain (44 %)
 Calf or thigh swelling (41
%),
 Wheezing (21 %)
 Rapid onset of dyspnea
 within seconds (46 %)
 within minutes (26 %)
 Tachypnea (54 %)
 Tachycardia (24 %)
 Rales (18 %),
 Decreased breath sounds
(17 %),
 Accentuated pulmonic
component of the second
heart sound (15 %)
 Jugular venous distension
(14 %)
Most Common Symptoms Most Common Signs