Tắc mạch phổi: Những vấn đề về phân loại, tiên lượng và quản lý - Sean M. Caples

• An evolving literature focused on the subset of patients at low-risk for complications (death, bleeding, recurrent VTE).. High Risk Jiminez, 2010[r]

Division of PULMONARY & CRITICAL CARE MEDICINE

Pulmonary Embolism:

Issues in Stratification, Prognosis

and Management

Sean M Caples, D.O., M.Sc

Pulmonary and Critical Care Medicine

• 66 M presents to ED with abdominal pain

• Similar to past diverticulitis (occasional sharp

In ED 5 hours Vital signs

• No signs of DVT

D-dimer > 2000 What’s next?

• What is the diagnosis and where should he be admitted?

Massive—High Risk

– Sustained hypotension (SBP < 90) for at least 15m or

on inotropes not due to another cause or

• Primary reperfusion (lytics, surgery, percutaneous)

• ICU level care

• ECMO

Jaff et al Circ 2011, EHS Guidelines

Submassive—Intermediate Risk

– Acute PE without hypotension but with either

• RV dysfnx

– Dilation – Elev BNP – ECG new RBBB or ischemia

Most who make it through ED survive

Causes of Death in those 30+ days

Natural History Most Deaths Occur Before Hospital

Identify? Rescue?

Submassive PE:

Why Stratify Risk?

• “Close monitoring” for early complications

• Optimize standard Tx (therapeutic heparin)

Smith, Morgenthaler et al, Chest, 2010

• Offer escalation in the case of deterioration

– Assuming we can detect it in time

• ? Reduce long-term complications

– (CTEPH 1-2%)

Pulmonary Embolism Severity Index

• 15K+ patients dismissals from 186 PA hospitals

– Data derived from dismissal coding (ICD-9)

• Primary outcome: 30-day mortality

• Prospective ext validation in 221 inpatients in France/Switz.

• 11 variables predict risk

– Demographic (2)

– Comorbid disease (3)

– Acute clinical findings (6)

– Another 7 lab values were indep associated but didn’t change modeling

• Didn’t include echocardiography, CT findings, biomarkers

Aujesky D, AJRCCM, 2005

Submassive/Intermediate Risk PE

RV Enlargement/Dysfunction

• Traditionally considered a marker of higher risk

• ~20% mortality rates in older cohorts (1990’s)

Contemporary reassessment—

increasing use of portable echo and CT angio

more common and may not be a marker of high risk

• RV abnormalities are common in hemodynamically stable patients

– 63% by CT measurement

– 23% by echocardiography

Jimenez, AJRCCM, 2014

RV Assessment by Echo

• Subjectivity; operator dependent

• Shape defies reliable size assessment

• No agreement on best measure

– Tricuspid annular plane systolic excursion (TAPSE) – McConnell’s sign—free wall down, apex contracts

• RV infarct mimics PE

• RVEF unreliable

Predictors of Early (30d) Mortality

ESC Guidelines, EHJ, 2014

Submassive PE:

Why Stratify Risk?

• “Close monitoring” for early complications

• Optimize standard Tx (therapeutic heparin)

Smith, Morgenthaler et al, Chest, 2010

• Offer escalation in the case of deterioration

– Assuming it’s detected

• ? Reduce long-term complications

– (CTEPH 1-2%)

• 1005 pts with RV dysfunction and elevated troponin but normotensive

• Randomized to heparin with or without

tenecteplase (with option for cross-over)

• Primary outcome: death or hemodynamic decompensation within 7d of randomization

NEJM, 2014

Patients at high risk for bleeding were excluded

? Reduced dose in the elderly

? Catheter directed

JAMA 2014

• NNT 65, NNH 18

• >65yrs: higher bleeding risk (NNH 11)

Submassive PE:

Why Stratify Risk?

• “Close monitoring” for early complications

• Optimize standard Tx (therapeutic heparin)

Smith, Morgenthaler et al, Chest, 2010

• Offer escalation in the case of deterioration

– Assuming we see it coming

• ? Reduce long-term complications

– (CTEPH 1-2%)

• 709 of the original 1,006 patients (28 of 76 sites)

• Followed median 38 mos

• No significant differences in long-term:

– Death since randomization (20 vs 18%; “low”)

– Functional limitation

– Suggestion of pulm HTN by echo parameters

– Confirmed CTEPH (2.1 vs 3.2%)

Which of the following excludes this patient from ED dismissal to home for

Rationale

• Influences:

– high in-patient census numbers

– resource and cost-containment

– The “incidental” PE detected on imaging performed for other indications

– Anecdotes of the patient that “didn’t need to be admitted”

– More patient-friendly home treatment (DOAC’s)

• An existing ED-to-Home pathway for DVT

• An evolving literature focused on the subset of patients at low-risk for complications (death, bleeding, recurrent VTE)

• 344 pts in 19 ED in Europe and US

• Low risk classification (PESI class I and II)

• Up to 5 days SQ LMWH then oral A/C

• Recurrent VTE at 90d (1 vs 0)

• Death at 90d (1 vs 1)

• Young (late 40’s), low rates of Ca (1-2%)

Aujesky et al Lancet, 2011

Risk Stratification: Tools

• Pulmonary Embolism Severity Index (PESI)

– 11 variables to predict risk via a numeric scale

• sPESI (simplified PESI)

– 6 variables

– Low risk vs High Risk Jiminez, 2010

• Hestia criteria (11 variables) Zondag, 2013

None incorporate biomarkers, RV characteristics

• Ottawa Hospital

– 1,100 bed major teaching hospital

– 50% of PE’s treated as an outpatient, empirically selected

• Seen in Thrombo Clinic within 24 hrs (7 days/wk)

• 2010-15; symptomatic PE, CT confirmed or high-prob V/Q

• Chart review of 576 inpatients vs 506 outpatients (matched)

• Primary outcome: adverse events at 14 days

– Recurrent VTE, major bleeding, death

J Thromb Haemost 2017

90 day event-free survival: Hospitalization might be risky

A few words about direct oral

anticoagulants (DOACs)

• Not studied in those with BMI > 40

• Contraindicated in valvular disease/prosthesis, pregnancy, end-stage liver disease

• Other idiosyncracies; reimbursement issues

• Ask Mayo Expert

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