Transcript Advantages & Disadvantages of Different Tests

‫بسم هللا الرحمن الرحيم‬
Identifying The Patient For
Thrombolysis Or
Thrombectomy
By
Ahmed Shafea Ammar
MD, FACC
Epidemiology
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>600,00 patients/ year in the US
50,000-200,000 deaths/ year in the US
3-month MR is 15-20%
10% of symptomatic PE are fatal at 1 hour
70% of symptomatic PE have DVT
50% of asymptomatic DVT have PE.
Semin Vasc Med 2001;1(2): 139-46
Risk Factors for DVT & PE
۰ Antiphospholipid Antibodies
Anticardiolipin & Lupus
Anticoagulant
Diagnosis of PE
Most Common S&S of APE Among 2454
Patients in ICOPER Registry
Symptom or sign
%
Dyspnea
RR> 20/min
HR>100 b/min
Chest pain
Cough
Syncope
Hemoptysis
82
60
40
49
20
14
7
Lancet 353:1386, 1999
Wells Clinical Bedside Scoring System for
APE
Parameter
Points
Clinical S&S of DVT
An alterative diagnosis is less likely
HR > 100
Immobilization or surgery within 4 weeks
Previous DVT/PE
Hemoptysis
Malignancy
Score < 4 APE is less likely
Score> 6 is a high risk
Thromb Haemost 83:416, 2000
3
3
1.5
1.5
1.5
1
1
Syndromes of Acute Pulmonary Embolism
Syndrome
Presentation
RVD
Therapy
Massive
sob, syncope, cyanosis, ↓BP
> 50% obst. of PV (v/q scan)
+ve
heparin + thrombolysis
or thrombectomy
Submassive
Normal BP, > 30% obst of PV
+ve
heparin ± thrombolysis
or thrombectomy
Small to mod.
Normal BP
-ve
heparin
Pulmonary inf.
Pleurisy (pain, rub), hemoptysis
consolidation, s. periph. emboli
rare
heparin& NSAID
Paradox. emb.
Systemic embolization eg CVS
rare
heparin, defect closure
Non-thrombotic
embolism
Air, Fat, Tumor, Amniotic fluid
rare
supportive
Risk Stratified Performance of Tests in PE
Test
Sensitivity Specificity
High risk
Intermed. risk
Low risk
ppv
npv
ppv
npv
ppv
npv
Helical CT
(%)
77
(%)
89
96
52
73
91
20
99
MRI
77
87
96
51
70
91
17
99
TTE
68
89
96
43
70
88
18
99
99
TEE
70
81
93
43
59
88
12
D-dimer
89
59
89
60
46
93
7
99
V/Q
98
10
80
58
30
93
3
99
Am Fam Physcian 2004, 162: 1245-8
Advantages & Disadvantages of
Different Tests
Test
Advantages
Rapid assessment of
Wells
questionnaire likelihood of APE
ABG &
Hypoxaemia
Rapid, widely
available
Disadvantages
Influenced by one
subjective Q about
alternative
diagnosis
Does not
discriminate well
between Pts with
& without PE
Advantages & Disadvantages of Different Tests
Test
D-dimer
ECG
Chest Xray
Advantages
Disadvantages
Rapid, widely available, Not specific, low ppv
high npv
Available, may indicate
RV strain
May be normal despite
PE
Identify mimics of PE
eg. pneumonia,
pneumothorax or CHF
May be normal despite
PE, Pts may have PE ±
pneumonia ± CHF
Note Humpton’s Humps & Wedge opacity
Advantages & Disadvantages of Different Tests
Test
Advantages
Disadvantages
Venous
ultrasound
May detect DVT
May be normal
despite PE
CT venography
May detect DVT & Low sensitivity for
obviat the need for calf DVT
US
Radiation
exposure
Identify high risk
Usually normal
Echocardiography patients if RVD is despite PE
present, may show
the embolus
Advantages & Disadvantages of Different Tests
Test
Lung
Scanning
PUL.
ANGIO
Spiral CT
Advantages
Disadvantages
Avoids high contrst
Often non
injection
diagnostic
Useful if normal or high
probability
Standard test
Displays pul. Vascular
morphology
Widely available
Direct visualization of
the thrombus and of
alternative diagnosis
Cost effective
Now, gold standard
Invasive &
Costly
Use of contrast
Radiation
exposure
Risk Stratification
The 3 main pillars for risk stratification are :
1- Assessment of Clinical & haemodynamic
status of the patient
2- Evidence of RV strain & infarction
3- Evidence of RV dilatation & dysfunction
Risk Stratification
1- Clinical Signs
Geneva Score Index
Clinical evidence of RVD :
JV distension
TR
↑ P2
2- ECG Signs
RV strain (T ↓ in v1 – v4)
New RBBB
S1Q3T3
The Geneva Score for PE Prognosis
Variable
Point Score
Cancer
CHF
Prior DVT
Hypotension
Hypoxemia
DVT on US
+2
+1
+1
+2
+1
+1
No of Points
% of Pts with adverse outcome
0
1
2
3
4
5
6
Throm Haemost 84:548, 2000
0
2.5
4.1
17.8
27.3
57.1
100
Risk Stratification
3- Echocardiographic Signs
* Direct visualization of a
large thrombus In the
main PA (TEE)
* RV dilatation
* TR
* RV hypokinesis sparing the
apex (Mac Connell sign)
* IVS flattening
* PH ± PA dilatation
* Lack of inspiratory collapse
of IVC
Outcomes with RV
Dysfunction
• 2-fold ↑ 14-day MR
• 3-fold ↑1-year MR
• ↑ risk of PE recurrence
• ?Increased risk of in
situ thrombosis in RV
and
Circulation 2002;121:877
SAX view
Note marked RV dilatation & IVS flattening during systole & diastole
Risk stratification
4- Spiral CT
A- RV dilatation relative to LV size.
RV dilatation and pulmonary vascular obstruction
(≥ 40%) on chest CT is a predictor of eary death after
APE
(Circulation 2005; 235(3): 798-803)
B- Saddle or large proximal thrombus
Massive PE
Note the large thrombus burden in the main
pul. branches
Risk stratification
5- Biomarkers :
Troponins,
Pro-BNP
BNP
Mechanism of cardiac biomarker level elevation in APE
Kucher, N. et al. Circulation 2003;108:2191-2194
Relation between cTnI concentrations ( 0.6 ng/ml) on admission and mortality (%).
La Vecchia, L et al. Heart 2004;90:633-637
Copyright ©2004 BMJ Publishing Group Ltd.
Time course of cardiac troponin I (cTnI) concentrations in patients with a
positive assay on admission.
La Vecchia, L et al. Heart 2004;90:633-637
Copyright ©2004 BMJ Publishing Group Ltd.
Circulation 2003;107:2545
Management Strategies
What is the optimal management for such embolus??
Thrombolysis, Catheter or Surgical Thrombectomy
Pulmonary embolism management strategy
Kucher, N. et al. Circulation 2003;108:2191-2194
Copyright ©2003 American Heart Association
Thrombolysis in APE
(State of The Art)
A meta-analysis of all randomized trials (11 trials including
748 pts) comparing thrombolytic therapy with heparin in
patients with APE, provides no evidence for a benefit of
thrombolytic therapy compared with heparin for the initial
treatment of unselected patients with APE.
However a benefit is clear in those at highest risk of
recurrence or death.
Whether patients with RVD and stable
hemodynamics should receive fibrinolytic therapy
is still unknown.
(Evid. Based Med., April 1, 2005; 10(2): 41 – 41)
Possible mechanisms by which thrombolysis
decreases mortality in patients with RVD
1- May prevent progressive RVD by lysis of massive PA
thrombi
2- May prevent the ongoing release of vasoactive factors,
such as serotonin, that may cause worsening
pulmonary vasoconstriction and RVF
3- May dissolve a significant amount of thrombi in the
source (e.g., pelvic and leg) veins to prevent
recurrent emboli
NB. Patients with APE are eligible for thrombolysis, if
they have new S&S within 2 weeks of 1st presentation
(Goldhaber S in Braunwald” Heart Disease 2005)
1,500,000 U/1 Hour streptokinase with
heparin is more effective than heparin
alone in PE with heart failure
• Randomized trial
intending to enroll 40
patients
• Massive PE,
hypotension, and heart
failure
• Stopped after 8 patients
Results
Group
SK+Heparin
Heparin
Outcome
0 of 4 died
4 of 4 died
Autopsy in 3 of 4 revealed
evidence of RV infarct and no
significant CAD
Jerjes-Sanchez et al. J Thromb Thrombolysis 1995;2:227-9
Heparin + Altepase (118 pts)
Heparin + Placebo (137 pts)
Konstantinides et al. NEJM 347 (15): 1143,October 10, 2002
Before thrombolysis
After thrombolysis
Note the change in RV size
NB. The risk of cerebral Hge is 1-2%
Contraindications for Thrombolytic Therapy
Absolute contraindications
• Active internal bleeding
• Recent spontaneous intracranial bleeding
Relative contraindications
• Major surgery, delivery, organ biopsy or puncture of noncompressible vessels within 10 days
• Ischaemic stroke within 2 months
• Gastrointestinal bleeding within 10 days
• Serious trauma within 15 days
• Neurosurgery or ophthalmologic surgery within 1 month
• Uncontrolled severe hypertension (systolic pressure >180
mmHg; diastolic pressure >110 mmHg
• Recent cardiorespiratory resuscitation
• Platelet count <100 000/mm3, prothrombin time less than 50%
• Pregnancy
• Bacterial endocarditis
• Diabetic haemorrhage retinopathy
What is the optimal therapy for massive PE &RVF ?
Surgery or Thrombolysis
Registry of Massive PE with RV failure (n=37)
Surgical embolectomy
(n=13)
77% survival
Recurrent PE in 1
Gulba et al. Lancet 1994;343:576-7
Thrombolysis
(n=24)
67% survival
Recurrent PE in 5
28% bleed rate
Role of Surgery
47 patients, underwent emergency surgical embolectomy for
massive central PE
The indications for surgery were (1) C/I to thrombolysis
(45%), (2) failed medical treatment (10%), and (3) RVD
(32%).
Preoperatively, (26%) patients were in cardiogenic shock, and
(11%) were in cardiac arrest.
There were (6%) operative & (12%) late deaths, 5 of which
were from metastatic cancer.
Actuarial survival at 1 and 3 years’ follow-up was 86% and
83%, respectively.
We now perform surgical pulmonary embolectomy not only
in patients with large central clot burden and hemodynamic
compromise but also in hemodynamically stable patients
with RVD documented by means of echocardiography.
J Thorac Cardiovasc Surg 2005;129:1018-1023
Surgically-Removed Thrombus
in Acute PE
What is the optimal embolectomy
route for massive PE & RVF?
Catheter embolectomy
vs
Surgical embolectomy
Advantages
Disadvantages
Advantages
Disadvantages
More accessible
Distal embolization
More control
Less experience
Various tools
Large clot burden
Revascularize
if needed
Need for
sternotomy
Limited Experience
No randomized trials
Catheter Embolectomy
Inteventional catheterization techniques includes :
Mechanical fragmentation of thrombus with PA
cath .
Clot puverization with a rotating basket catheter.
Rheolytic thrombectomy.
Combination of mechanical fragmentation and
thrombolysis.
Catheter embolectomy is hindered by devices that
are designed normally to remove small arterial
clots rather than decompressing massive PE.
Suction catheter embolectomy + full dose thrombolysis
Duration of Anticoagulant Therapy
(INR 1.5-2)
Summary (1)
Risk Stratification based on Geneva score index
(>4), ↑ S biomarkers, Echo signs of RVD and
evidence of large thrombus burden on helical CT
identification of patients for thrombolysis or
thrombectomy
Thrombolytic therapy is indicated in patients
with massive PE, as shown by shock /or hypotension
+ RVD
The use of thrombolytic therapy in patients with submassive PE (RVD without hypotension) is
controversial.
Thrombolytic therapy is not indicated in patients
without right ventricular overload.
Summary (2)
Surgical embolectomy is reserved for patients
with massive PE (large thrombus burden)
with C/I to thrombolysis and those having
PTO or RV or RA thrmbus
Catheter embolectomy can be used for
patients with massive PE (moderate
thrombus burden & C/I to thrombolysis
Please, do not rush
Always, weigh:
Safety
Efficacy
Pathophysiology Epidemiology & costs Management Fibrinolytic therapy Fibrinolytic trials Clinical questions - a) - b) - c) - d) - e)
Ahmed Shafea
MD, FACC