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Pulmonary Embolism: Difference between revisions
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{{main|Thrombolysis}} | {{main|Thrombolysis}} | ||
Massive PE causing hemodynamic instability (shock and/or hypotension, defined as a systolic blood pressure <90 mmHg or a pressure drop of 40 mmHg for>15 min if not caused by new-onset arrhythmia, hypovolemia or sepsis) is an indication for [[thrombolysis]], the enzymatic destruction of the clot with medication. It is the best available medical treatment in this situation and is supported by clinical guidelines.< | Massive PE causing hemodynamic instability (shock and/or hypotension, defined as a systolic blood pressure <90 mmHg or a pressure drop of 40 mmHg for>15 min if not caused by new-onset arrhythmia, hypovolemia or sepsis) is an indication for [[thrombolysis]], the enzymatic destruction of the clot with medication. It is the best available medical treatment in this situation and is supported by clinical guidelines. <cite>REFNAME33</cite> <cite>ESC</cite> <cite>REFNAME34</cite> | ||
The use of thrombolysis in non-massive PEs is still debated. The aim of the therapy is to dissolve the clot, but there is an attendant risk of bleeding or [[cerebrovascular accident|stroke]].< | The use of thrombolysis in non-massive PEs is still debated. The aim of the therapy is to dissolve the clot, but there is an attendant risk of bleeding or [[cerebrovascular accident|stroke]]. <cite>REFNAME35</cite> The main indication for thrombolysis is in submassive PE where right ventricular dysfunction can be demonstrated on [[echocardiography]], and the presence of visible thrombus in the atrium. <cite>REFNAME36</cite> | ||
===Surgery=== | ===Surgery=== | ||
[[File:Inferior vena cava filter.jpg|thumb|right|Used inferior vena cava filter.]] | [[File:Inferior vena cava filter.jpg|thumb|right|Used inferior vena cava filter.]] | ||
Surgical management of acute pulmonary embolism ([[pulmonary thrombectomy]]) is uncommon and has largely been abandoned because of poor long-term outcomes. However, recently, it has gone through a resurgence with the revision of the surgical technique and is thought to benefit selected patients.< | Surgical management of acute pulmonary embolism ([[pulmonary thrombectomy]]) is uncommon and has largely been abandoned because of poor long-term outcomes. However, recently, it has gone through a resurgence with the revision of the surgical technique and is thought to benefit selected patients. <cite>REFNAME37</cite> | ||
Chronic pulmonary embolism leading to [[pulmonary hypertension]] (known as ''chronic thromboembolic hypertension'') is treated with a surgical procedure known as a [[pulmonary thromboendarterectomy]]. | Chronic pulmonary embolism leading to [[pulmonary hypertension]] (known as ''chronic thromboembolic hypertension'') is treated with a surgical procedure known as a [[pulmonary thromboendarterectomy]]. | ||
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===Inferior vena cava filter=== | ===Inferior vena cava filter=== | ||
{{main|inferior vena cava filter}} | {{main|inferior vena cava filter}} | ||
If anticoagulant therapy is [[contraindication|contraindicated]] and/or ineffective, or to prevent new emboli from entering the pulmonary artery and combining with an existing blockage, an [[inferior vena cava filter]] may be implanted.< | If anticoagulant therapy is [[contraindication|contraindicated]] and/or ineffective, or to prevent new emboli from entering the pulmonary artery and combining with an existing blockage, an [[inferior vena cava filter]] may be implanted. <cite>REFNAME38</cite> | ||
==Prognosis== | ==Prognosis== | ||
[[File:Saddle thromboembolus.jpg|thumb|Large saddle embolus seen at PA.]] | [[File:Saddle thromboembolus.jpg|thumb|Large saddle embolus seen at PA.]] | ||
[[Mortality rate|Mortality]] from untreated PE is said to be 26%. This figure comes from a trial published in 1960 by Barrit and Jordan | [[Mortality rate|Mortality]] from untreated PE is said to be 26%. This figure comes from a trial published in 1960 by Barrit and Jordan <cite>Barritt</cite>, which compared anticoagulation against placebo for the management of PE. Barritt and Jordan performed their study in the [[Bristol Royal Infirmary]] in 1957. This study is the only placebo controlled trial ever to examine the place of anticoagulants in the treatment of PE, the results of which were so convincing that the trial has never been repeated as to do so would be considered unethical. That said, the reported mortality rate of 26% in the placebo group is probably an overstatement, given that the technology of the day may have detected only severe PEs. | ||
Prognosis depends on the amount of lung that is affected and on the co-existence of other medical conditions; chronic embolisation to the lung can lead to [[pulmonary hypertension]]. After a massive PE, the embolus must be resolved somehow if the patient is to survive. In thrombotic PE, the blood clot may be broken down by [[fibrinolysis]], or it may be organized and recanalized so that a new channel forms through the clot. Blood flow is restored most rapidly in the first day or two after a PE.< | Prognosis depends on the amount of lung that is affected and on the co-existence of other medical conditions; chronic embolisation to the lung can lead to [[pulmonary hypertension]]. After a massive PE, the embolus must be resolved somehow if the patient is to survive. In thrombotic PE, the blood clot may be broken down by [[fibrinolysis]], or it may be organized and recanalized so that a new channel forms through the clot. Blood flow is restored most rapidly in the first day or two after a PE. <cite>REFNAME39</cite> Improvement slows thereafter and some deficits may be permanent. There is controversy over whether or not small subsegmental PEs need to be treated at all <cite>REFNAME40</cite> and some evidence exists that patients with subsegmental PEs may do well without treatment. <cite>REFNAME41</cite> <cite>REFNAME42</cite> | ||
Once anticoagulation is stopped, the risk of a fatal pulmonary embolism is 0.5% per year.< | Once anticoagulation is stopped, the risk of a fatal pulmonary embolism is 0.5% per year. <cite>REFNAME43</cite> | ||
===Predicting mortality=== | ===Predicting mortality=== | ||
The PESI and Geneva prediction rules can estimate mortality and so may guide selection of patients who can be considered for outpatient therapy.< | The PESI and Geneva prediction rules can estimate mortality and so may guide selection of patients who can be considered for outpatient therapy. <cite>REFNAME44</cite> | ||
===Underlying causes=== | ===Underlying causes=== | ||