venous thrombosis pulmonary embolism深静脉血栓形成和肺栓塞课件

Venous Thromboembolism,Abi Senthivel MD PGY 3 Emory Family Medicine Residency Program,Objective,Incidence Pathophysiology Diagnosis Treatment Prevention,Venous Thromboembolism,Deep Venous Thrombosis,Pulmonary Embolism,Incidence of VTE,900,000 each year in US Several 100,000 hospitalizations 300,000 deaths These numbers are estimates only. 1 in 100 in people over 80yrs Am J Prev Med. 2010 Apr;38(4 Suppl):S502-9. doi: 10.1016/j.amepre.2010.01.010.,Why is is important to recognize DVT/PE?,High Mortality,10 to 30% of people with PE will die within one month of diagnosis. Sudden Death is the first presentation in 25% of patients with PE,And High Morbidity,50% will have long term complications (post-thrombotic syndrome) 33% will have recurrence within 10 years,PathoPhysiology of VTE,Virchows Triad,Rudolph Virchow, 1858,Risk Factors,Inherited Thrombophilia Factor V Leiden mutation Prothrombin gene mutation Protein S deficiency Protein C deficiency Antithrombin (AT) deficiency Dysfibrinogenemia,Acquired Disorders Malignancy Presence of a central venous catheter Surgery Trauma Pregnancy/OCP/HRT Drugs Immobilization Congestive failure,Acquired Risk Factors cont,Antiphospholipid antibody syndrome Myeloproliferative disorders Polycythemia vera Essential thrombocythemia Paroxysmal nocturnal hemoglobinuria Inflammatory bowel disease Nephrotic syndrome,Pathophysiology of PE,Most PEs arise from DVT of LE But some may arise from Right heart Pelvic veins Renal veins UE veins,Lets Meet Ms Maria,Maria,38 yr old female presents with pain and mild swelling in L LE. Pt was hiking recently when she slipped, fell and injured R knee. Her knee immediately swelled. She felt unstable w/ walking due to pain and sought care at a local ER. A knee immobilizer was placed. She followed up with an orthopedic doctor who diagnosed an acute ACL rupture. An MRI confirmed this and she underwent allograph repair 3 weeks ago. She is currently doing rehab with a PT.,Maria (cont),PMH: Negative PSH: ACL repair (6/22/13) Meds: Ibuprofen prn / Vicodin prn / Ortho Tricyclen Allergies: NKDA Soc Hx: Scrub tech at EUH No Tob / Rare Etoh,Maria on exam,Vitals: T 97.2 P 90 BP 110/70 R 14 Pulm: CTA CV: Regular Ext: Moderate swelling about R knee w/ healing incision. 1+ pitting edema L LE. Mild pain with squeezing calf on L leg. None on R leg. Negative Homans sign. Calf circumference is 1 cm larger L than R.,What is the probability that Maria has a DVT?,Modified Wells Criteria for DVT,Modified Wells Criteria for DVT,2 or more Likely 0 to 1 Unlikely Wells PS, Anderson DR, Rodger M et al. (2003). Evaluation of D-dimer in the diagnosis of 8 suspected deep-vein thrombosis. New England Journal of Medicine 349: 122735,Lets Meet Mr Albert,Albert,62 yr old male presents to the ER with complaint of pleuritic CP. Present x 1 day. No injury. Feels SOB with walking. No fever. No cough. No LE pain. PMH: Colon CA s/p L colectomy on 6/20 / HTN / BPH Meds: Lisinopril / Tamsulosin / ASA / MVI NKDA Soc Hx: No Tob / No Etoh,Albert,Physical T 99.1 P 110 BP 135/85 R 22 O2 sat 95% RA Pulm: CTA, good AE CV: Regular, No murmurs Ext: No edema. Negative Homans sign,What is the likelihood of a PE in Mr. Albert?,Wells Criteria for PE,Modified Wells Criteria for PE,4: Likely 4 or less: Unlikely Wells PS, Anderson DR, Rodger M et al. (2003). Evaluation of D-dimer in the diagnosis of 8 suspected deep-vein thrombosis. New England Journal of Medicine 349: 122735,Diagnosing DVT,DVT - Physical Exam,Calf tenderness,Homans Sign,Differential Swelling,,Diagnostic Tests for DVT,D- dimer Ultrasound Contrast Venography,Ultrasonography,Duplex scan of LE Compressibility of the vein Doppler flow within the vein Symptomatic patient with proximal LE DVT Sensitivity: 89-96% Specificity: 94-99%,Ultrasonography,Asymptomatic patient with proximal LE DVT Sensitivity: 47-62% Symptomatic patient with distal LE DVT Sensitivity: 73-93%,Venography,Gold standard for DVT But not recommended as first line due to high cost, risks ad technical difficulties,Adapted with permission from Institute for Clinical Systems Improvement. Copyright 2012. Health care guideline: venous thromboembolism diagnosis and treatment.,Diagnosing PE,Signs and Symptoms of PE,Signs in Massive P.E.,“Massive PE”: Hemodynamic instability SBP /=40mmHg over 15 min Elevated central venous pressure Signs as before PLUS: Acute right heart failure Elevated J.V.P. Right-sided S3 Parasternal lift,Diagnostic Tests,Imaging Studies CXR V/Q Scans Spiral Chest CT Pulmonary Angiography Echocardiograpy Laboratory Analysis CBC D-Dimer ABGs BNP Cardiac Enzymes - Troponin Ancillary Testing EKG Pulse Oximetry,Common findings,D-Dimer elevation 500 ng/ml A-a gradient 20 mm Hg BNP or proBNP elevation Sensitivity and Specificity are approx 60% Troponin elevation 30-50% of mod/large PEs have troponin elevation,ABG,ABG: Hypoxemia Hypocapnia (low CO2) Respiratory Alkalosis Massive PE: hypercapnia, mix resp and metabolic acidosis (inc lactic acid) Patients with RA pulse ox readings 95% are at increased risk of in-hospital complications, resp failure, cardiogenic shock, death,But,Most patients with a PE have a normal pulse oximetry, and most patients with an abnormal pulse oximetry will not have a PE. The A-a gradient is a better measure of gas exchange than the pO2, but it is nonspecific and insensitive in ruling out PE BNP is insensitive but is a good prognostic measure when combined with Troponin,D-dimer,Degradation product of fibrin 500 is abnormal Sensitivity: High, 80-85% Specificity: Low Negative Predictive Value: Excellent 93% to100%,D-dimer Test False Positives,Pregnancy Post Partum 80 Sepsis Hemorrhage CVA AMI Collagen Vascular Disorder Hepatic Impairment,41,Chest radiograph findings in patients with PE,Result Percent Cardiomegaly 27% Normal study 24% Atelectasis 23% Elevated Hemidiaphragm 20% Pulmonary Artery Enlargement 19% Pleural Effusion 18% Parenchymal Pulmonary Infiltrate 17%,Alberts Chest X-ray,Westermarks Sign,Hamptons Hump,Chest X-ray,Westermarks sign A dilation of the pulmonary vessels proximal to the embolism along with collapse of distal vessels, sometimes with a sharp cutoff. Hamptons Hump A triangular or rounded pleural-based infiltrate with the apex toward the hilum, usually located adjacent to the hilum.,But,Most chest x-rays in patients with PE are nonspecific and insensitive,Albert - EKG,EKG Findings in PE,Most Common Findings: Tachycardia or nonspecific ST/T-wave changes Acute cor pulmonale or right strain patterns Tall peaked T-waves in lead II (P pulmonale) Right axis deviation RBBB S1-Q3-T3 (occurs in only 20% of PE patients),Echocardiogram,Increased Right Ventricle Size Decreased Right Ventricular Function Tricuspid Regurgitation Rarely: RV thrombus Regional wall motion abnormalities that spare the right ventricle apex (McConnells Sign),49,Spiral (Helical) Chest CT,Advantages Noninvasive and Rapid Sensitivity: 40-100% Specificity: 78-100% Disadvantages Costly ($600 - 900/scan) Risk to patients with borderline renal function Hard to detect subsegmental pulmonary emboli,Ventilation/Perfusion Scan,Relatively noninvasive Preferred test in pregnant patients, contrast allergy patients 50 mrem vs 800mrem (with spiral CT),50,51,V/Q Scan,Technique Interpretation Normal Low probability/”nondiagnostic” (most common) High Probability Simplified approached to the interpretation of results: High probability Treat for PE Normal Scan If low pre-test, no further testing Low probability Pursue another study (CT, Angio),52,Pulmonary Angiography,“Gold Standard” Performed in an Interventional Cath Lab Positive result is a “cutoff” of flow or intraluminal filling defect “Last Resort”,PE Diagnosis,VQ scanning versus Spiral CT Chest Randomized trial of patients suspected of having PE, n=1471 False Negative Rate Spiral CT 0.6% VQ Scan 1.0%,PE and DVT Diagnosis Algorithm,Am Fam Physician. 2007 Dec 1;76(11):1712-1713,Another newer Algorithm,Am Fam Physician. 2012 Nov 15;86(10):913-919,Hypercoagulability Work Up,Am Fam Physician. 2004 Jun 15;69(12):2841-2848.,Treatment of VTE,Goals of Treatment of DVT,To stop clot propagation Prevent clot recurrence Prevent PE and secondary pulmonary hypertension,DVT Treatment,At least 6 -12 weeks of Anticoagulation using heparin followed by warfarin (Coumadin). Nonpharmacologic measures limb elevation and local application of heat. Activity should be minimal for several days Graded elastic compression stockings 50 percent reduction in the incidence of postphlebitic syndrome.,Goals of Treatment of PE,Prevent death from a current embolic event Reduce the likelihood of recurrent embolic events Minimize the long-term morbidity of the event,63,Treatment of P.E.,Respiratory Support: Oxygen, intubation Hemodynamic Support: IVF, vasopressors Anticoagulation Thrombolysis IVC Filter,Anticoagulation,Start during resuscitation phase itself Evaluate patient for absolute contraindication If suspicion high, start empiric anticoagulation,Anticoagulation (contd),HEPARIN: Lovenox: if hemodynamically stable, no renal function 1mg/kg BID OR 1.5mg/kg QDay Heparin gtt: if hypotension, renal failure 80units/kg bolus then 18units/kg infusion Goal PTT1.5 to 2.5 times the upper limit of normal Provides immediate thrombin inhibition, which prevents thrombus extension Does not dissolve existing clot Will not work in patients with antithrombin III def. In this case use hirudins Few absolute contraindications,68,Anticoagulants,COUMADIN: Start once acute anticoagulation achieved Start with 5mg PO qday OR 10mg PO q day If start with 10mg then achieve therapeutic INR 1.4 days sooner Complications and morbidity no different in 5mg or 10mg start Goal INR 2 to 3,Duration of Anticoagulation for VTE,*From American College of Chest Physicians,70,Thrombolysis,Fibrinolytic Therapy (Alteplase) Indications: Documented PE with: Persistent hypotension Syncope with persistent hemodynamic compromise Significant hypoxemia +/- patient with acute right heart strain Approved Altivase regimen is 100mg as a continuous IV infusion.,Thrombolysis,Hold anticoagulation during thrombolysis infusion, then resumed Associated with higher incidence of major hemorrhage,IVC Filter,Indication: Absolute contraindication to anticoagulation (i.e. active bleeding) Recurrent PE during adequate anticoagulation Complication of anticoagulation (severe bleeding) Also: Pts with poor cardiopulmonary reserve Recurrent P.E. will be fatal Patients who have had embolectomy Prophylaxis against P.E. in select patients (malignancy),Embolectomy,Surgical or catheter Indication: Those who present severe enough to warrant thrombolysis In those where thrombolysis is contrai