Acute Venous Pulmonary Embolism

1
Acute Venous Pulmonary Embolism
Goals of Therapy

• Restore cardiopulmonary hemodynamics
• Avoid recurrence
• Avoid chronic thromboembolic pulmonary
  hypertension

with their associated morbidity and mortality
2
Pulmonary Embolism
Chronic Thromboembolic Pulmonary Hypertension
After First Episode of PE
6 months 1.0
1 year 3.1
2 years 3.8
CTPH
Pengo V, et al NEJM 20043502257
3
Pulmonary Embolism
Recommendations for Anticoagulation
Similar to DVT
4
Thrombolytic Rx for PE
NIH Trials Early Results

• Rapid improvement of arteriogram and lung scans
  (Plt.05)
• Reduced PA and R arterial pressure (Plt.05)
• No difference in overall mortality (study not
  designed to detect mortality difference)
• Less mortality with massive PE

Circulation 1973 39 SII-1 JAMA 1974
2291606-13
5
Thrombolytic Rx for PE
NIH Trials Long-Term Results

• Improved pulmonary cap blood vol (Plt.001)
• Improved O2 diffusing capacity (Plt.05)
• Reduced PA pressure _at_ rest and exercise (Plt.05)
• Reduced PVR _at_ rest and exercise (Plt.05)
• Less recurrent DVT and PE (Plt.05)
• Less CHF (NYHA II-IV) (Plt.05)

Circulation 1973 39 SII-1 JAMA 1974
2291606-13
6
Massive Pulmonary Embolism
Lytic Rx vs. Anticoagulation
Randomized Trial
Heparin Alone
SK Heparin
100 (4/4)
0 (0/4)
Mortality
Ethics committee terminated trial!
Jerjes-Sanchez C, et al J Thromb Thrombolyis
1995 2227
7
Lytic Rx for PE Randomized Trial
Hemodynamic Outcome
P-value
Heparin
rt-PA
Right Vent. Fct. (24 hrs)
0.005
17
39
Improved
17
2
Worse
0.01
26 cm2
23.8 cm2
End diastolic area
0.0001
1.5
14.6
Improved Pulm. Per.
0.06
9
0
Recurrent PE (14 days)
Goldhaber SZ Lancet 1993
8
Pulmonary Embolism
Lytic Rx vs. Anticoagulation

• Multicenter registry
• Thrombolytic Rx vs. anticoagulation
• 30-day mortality lower in patients receiving
  lytic Rx (4.7 vs. 11.1, P0.016)
• Primary lysis was only independent predictor of
  survival (multivariate analysis)

Konstantinides S, et al Circulation 1997
9
Pulmonary Embolism
Pre-Rx
10
Pulmonary Embolism
Pre-Rx