Epidemiology and diagnosis of acute pulmonary embolism

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Epidemiology and diagnosis of acute pulmonary
embolism

• Dr Sam Z Goldhaber
• Associate Professor of Medicine
• Harvard Medical School
• Staff Cardiologist
• Brigham and Womens Hospital
• Boston, MA

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Risk factors for PE

• Nurses Health Study
• Obesity
• (RR 3.0, with BMI gt29)
• Cigarette smoking
• (RR 2.1, with gt 35 cigs/d)
• Hypertension
• (RR 1.5)

JAMA 1997 277642
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Hypercoagulability work-upHigh yield (gt 20)

• Factor V Leiden
• Genetic mutation that causes
• resistance to activated protein C
• Plasma homocysteine level
• Rx with folate, B6, B12
• Lupus anticoagulant screen
• Requires intensive anticoagulation
• Possible steroid/ASA responsiveness

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Leiden/recurrent VTEafter discontinuing warfarin

• RR 4.7 (p 0.047)
• (PHS Circulation 1995 922800)
• RR 2.4 (p lt 0.01)
• (Padua NEJM 1997 336399)
• No increased risk
• (Rintelen Thromb Haemostas 996 75229)

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ACLA and VTE412 Swedish patients

• 14 ACLA in men
• 17 ACLA in women
• 29 recurrence in ACLA positive
• vs 14 recurrence in ACLA negative
• 15 vs 6 4-year mortality

Am J Med 998 104332
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Prothrombin gene mutation

• risk DVT/PE
• (Ann Intern Med 1998 12989)
• risk cerebral vein thrombosis
• (NEJM 1998 3381793)

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Hypercoagulability work-upLow yield

• antithrombin III deficiency
• (spurious value on heparin)
• protein C deficiency
• (spurious value on warfarin, BCP or when
  pregnant)
• protein S deficiency
• (spurious value on warfarin, BCP or when
  pregnant)

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Signs/Sx PE (n 131)

• Observation Rate
• Dyspnea 77
• Chest pain 55
• Cyanosis 18
• Hemoptysis 13
• Syncope 10

Arch Intern Med 1991 151933
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BLOOD ACTIVATION
F XIII F XIIIa
thrombin
fibrinogen fibrin monomers fibrin clot
FDP fibrinogen degradation products
D
D
plasmin
D-Dimers (XDP)
FIBRINOLYSIS
Figure 1 D-Dimer is exclusively from fibrin clot
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D-Dimer for PE diagnosisOverview of 9 trials (n
908)
Thromb Haemostas 1994 711-6
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High probability lung scansare insensitive for PE
JAMA 1990 2632753-9
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Normal (left) and abnormal (right) venous
ultrasounds (C compression)
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Venography for suspected PE
Hull et al. Ann Intern Med 1983 98891
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CT scan with contrast showing main bilateral
pulmonary embolism
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Echocardiogram suggesting a PE. Diastole on the
left, systole on the right
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PE diagnosis strategy
Lung (or CT) scan
High probability
Intermediate
Normal
TREAT
or low probability
STOP W/U
High D-dimer
Normal D-dimer
CONTINUE W/U
STOP W/U
If leg U/S normal
If Echo normal
PAgram (or CT)
PAgram (or CT)