ESC guideline 2019 Intern Chayanid Kunanukulwatana 61713 Classes of recommendations Levels of evidence Epidemiology Annual incidence rates for PE range from 39115 per 100000 population ID: 932374
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Slide1
Acute pulmonary embolism
ESC guideline 2019
Intern
Chayanid
Kunanukulwatana
61713
Slide2Classes of recommendations
Slide3Levels of evidence
Slide4Epidemiology
Annual incidence rates for PE range from 39-115 per 100,000 population
Globally
the third most frequent
acute cardiovascular syndrome behind myocardial infarction and stroke.
Slide5Predisposing factors
In 40% of patients with PE, no predisposing factors are found.
Slide6Predisposing factors
Slide7Predisposing factors
Slide8Pathophysiology
Slide9Diagnosis
Clinical presentation
In most cases are
Non-specific
.
Dyspnea, Pre-syncope or Syncope, or Hemoptysis
Chest pain
caused by pleural irritation due to distal emboli causing pulmonary infarction.
Hemodynamic instability is a rare
but important form of clinical presentation
Asymptomatic
or discovered incidentally during diagnostic workup for another disease
Central PE, chest pain may have a
typical angina character
, possibly reflecting RV ischemia, and requiring differential diagnosis from an acute coronary syndrome or aortic dissection
Slide10Diagnosis
Chest
X-ray
o
Excluding other causes of dyspnea or chest pain
o
Westermark’s
sign
o
Hampton’s hump sign
EKG
o
Mild : sinus tachycardia
o
Severe : RV strain, S1Q3T3 pattern, incomplete or complete RBBB
Slide11Slide12Slide13The Revised Geneva clinical prediction rule
Slide14Diagnosis
D-dimer testing
• Elevated in the presence of acute thrombosis because simultaneous activation of coagulation and fibrinolysis
• NPV is high, PPV is low
• Frequently elevated in cancer, hospitalized patients, sever infection, inflammatory disease and pregnancy
• Low – intermediate clinical probability
D-dimer testing is not useful for confirmation of PE.
Slide15Slide16Diagnosis
Echocardiography
Acute PE may lead to RV pressure overload and dysfunction
Slide17Recommendation Diagnosis
Slide18Assessment of pulmonary embolism severity and the risk of early death
Slide19Treatment in The Acute Phase
Slide20Slide21Slide22Haemodynamic
and respiratory support
Oxygen therapy and ventilation
Hypoxemia is one of the features of severe PE
(Mismatch between ventilation and perfusion)
Indicated in patients with PE and SaO2 <90%.
Slide23Pharmacological treatment of acute right ventricular failure
Slide24Initial anticoagulation
Parenteral anticoagulation
High or intermediate clinical probability of PE
LMWH and fondaparinux are preferred
Lower risk major bleeding, heparin induced thrombocytopenia, no monitoring levels
Slide25Initial anticoagulation
Non-vitamin K antagonist oral anticoagulants (NOAC)
Directly inhibit one activated coagulation factor.
Fixed doses without routine laboratory monitoring.
Fewer interactions with other drugs.
Preferred over VKA
Non-inferiority compared with combination of LMWH with VKA, significantly reduced rates of major bleeding
No recommended : severe renal impairment, pregnancy - lactation, antiphospholipid antibody syndrome
Slide26Initial anticoagulation
Vitamin K antagonists
The gold standard in oral anticoagulation
When VKAs are used, anticoagulation with UFH,LMWH, or fondaparinux should be continued in parallel with the oral anticoagulant for >_5 days and until INR value has been 2.0-3.0 for 2 consecutive days.
Slide27Reperfusion treatment
Systemic thrombolysis
Faster improvements
reduction in RV dilation on echocardiography.
Initiated within 48
hr
of symptom onset
Slide28Slide29Slide30Treatment strategies
Emergency treatment of high-risk pulmonary embolism
Slide31Definition of
hemodynamic instability
Delineates acute high-risk pulmonary embolism
One of the following clinical manifestations at presentation
Slide32Treatment of intermediate-risk pulmonary embolism
Treatment strategies
Slide33Treatment of intermediate-risk pulmonary embolism
Treatment strategies
Slide34Treatment strategies
Management of low-risk pulmonary embolism
: triage for early discharge and home treatment
early discharge and continuation of anticoagulant treatment at home should be considered if three sets of criteria are fulfilled:
the risk of early PE-related death or serious complications is low
there is no serious comorbidity or aggravating conditions that would mandate hospitalization
proper outpatient care and anticoagulant treatment can be provided, considering the patient’s compliance, and the possibilities offered by the healthcare system and social infrastructure.
Slide35Slide36Slide37Slide38Pulmonary embolism and pregnancy
Slide39Estimated amounts of radiation absorbed in procedures
Slide40Treatment of pulmonary embolism in pregnancy
Slide41Reference