1. Pulmonary Embolism
Salah Abusin, MD, MRCP
Cardiology Fellow
Chicago, IL
Secretary General
Sudanese American Medical Association

2. Outline
• Definition • Management
• Risk Factors – Anticoagulation
• Types – Thrombolysis
• Natural History – IVC filters
• Symptoms – Embolectomy
• Signs • Surgical
• • Catheter Based
Investigations
• Diagnosis

4. History
• A 61 year old male
– New onset shortness of breath for 4 days.
– He also noticed a cough, with blood tinged
sputum.
– He had no chest pain, no orthopnea or
paroxysmal nocturnal dyspnea, or fever.
– He used his albuterol inhaler several times with no
improvement in his shortness of breath
• .

5. • Past history:
– Hypertension
– Asthma
– Remote history (10 years prior to current
presentation) of left lower limb swelling that
subsided after treatment for 6 months.
• Social history: Smoker 40 pack year history
• Family history: no relevant family history.
• Drug history:
– fluticasone/Salmeterol combination inhaler twice
daily,
– albuterol inhaler as needed for shortness of breath
– hydrochlorothiazide 12.5mg once daily

6. Physical Examination:
• Vital Signs:
– HR 113/min,
– BP 150/93,
– respiratory rate 22/min,
– oxygen saturation via pulse oximetry 89% on
room air,
– temperature 97.2° F (36.2 °C)

7. • HEENT: (Head, Eyes, Ear, Nose, Throat
examination) was normal.
• JVP was not raised.
• Chest clear no wheezes, or crackles.
• Abdomen soft non tender, no palpable liver,
spleen.
• Lower extremities: no edema, no other
abnormalities
• PEFR (peak expiratory flow rate) was above
75% of predicted

8. What is your differential diagnosis?
What test would you like to perform
next?

9. Investigations
• Chest X ray  Clear Lung fields
• ECG  Sinus Tachycardia
• Basic metabolic panel (BMP) includes Na, K,
HCO3, Chloride, BUN, Creatinine was within
normal limits.
• Complete blood count: Hb 15.9, WBC 7200
with normal differential, platelet count 270.
• Liver function test, and liver enzymes were
within normal limits.

10. Arterial Blood Gas on Room Air
• pH 7.42 (normal)
• pCO2 33.2 (mildly reduced)
• pO2 55 (moderately reduced)
• Oxsat 87%

11. What would you like to do next?

12. CT Chest – PE Protocol

13. Definition of Pulmonary Embolism
• obstruction of the pulmonary artery or one of
its branches by material (eg, thrombus, tumor,
air, or fat) that originated elsewhere in the
body

14. Risk Factors

15. Types
• Acute
– Massive (BP <90/40 >15mins)
– Submassive – doesn’t meet above definition
• Chronic
• Saddle PE
– Embolus lodges at the Main PA bifurcation

16. Natural History
• 30% die if untreated
• Usually due to recurrent PE

18. Symptoms
• Dyspnea at rest or with exertion (73%)
• Pleuritic pain (44 %),
• calf or thigh pain (44%),
• calf or thigh swelling (41%),
• cough (34%),
• >2-pillow orthopnea (28% ),
• wheezing (21 %)
PIOPED II. Stein PD , Beemath A et al
Am J Med. 2007;120(10):871.

19. Signs
• tachypnea (54%),
• tachycardia (24%),
• crackles (18%),
• decreased breath sounds (17%),
• Loud S2 (15%),
• Raised JVP (14 %)
PIOPED II. Stein PD , Beemath A et al
Am J Med. 2007;120(10):871.

20. Laboratory Investigations
• ABGs
– Hypoxemia
– Hypocapnia
– Respiratory alkalosis
– Hypercapnia, Resp acidosis (if massive)
– Metabolic acidosis (if massive)
• Troponin
– Elevated in moderate to severe PE

21. D dimer
• Fibrin degradation product
• Is elevated in most patients with PE
• High negative predictive value
• i.e. useful to rule out PE in patients with low
to intermediate pretest probability

22. ECG
• Sinus tachycardia
• Non specific ST/T changes
• Classical findings are uncommon
– S1Q3T3 pattern,
– RV strain,
– new incomplete RBBB

23. Chest Xray
• Usually abnormal but doesn’t differentiate PE
from other diagnoses
PE No PE
Atelectasis or a pulmonary 69% 58%
parenchymal abnormality
Pleural Effusion 47% 39%
Normal 12%
Stein et al
Chest. 1991;100(3):598

24. VQ Scan
• Interpreted as probability i.e.
– Low Probability
– Intermediate Probability
– High Probability
• Diagnosis of PE using VQ scan requires
integration of the pretest probability
• Normal VQ Scan virtually excludes PE

26. CT Chest
• Advantages
– High Specificity for main, lobar and segmetal vessels
– Rapidity
– Diagnosis of other disease entities
• Disadvantages
– Availability
– Expense
– Less sensitivity with subsegmental vessels
– Contrast Load

27. Diagnosis
• Clinical findings are generally non specific,
variable, and common with other conditions
• Results of Diagnostic Investigations (VQ, CT)
have to be integrated with the pretest
probability of PE

28. Determine Pretest Probability

30. Management
• Anticoagulation (Acute)
– Unfractionated Heparin
– Low Molecular Weight Heparin
– Fondaparinux
• Anticoagulation (Chronic)
– Warfarin
• New agents
– Dabigatran
– Rivaroxaban

31. Unfractionated Heparin
• Proven to work since 1960
• Intravenous
– Bolus of 80u/kg followed by infusion at 18u/kg/hr
– Titrate to target PTT 1.5-2.5x the control aPTT
• Subcutaneous
– After IV bolus of 5000u, 250u/kg BID
– SQ bolus of 333u/kg
– aPTT Not monitored

32. LMW Heparin
• Administered subcutaneously
• Examples include
– Enoxaparin  BID or once daily dosing
– Dalteparin once daily
– Nadroparin BID dosing (not for use if wt >100kg)
– Tinzaparin
• Do not require monitoring in most cases

33. LMW Heparin vs UF Heparin
• Compared with IV UFH LMW Heparin had
– less mortality,
– less thromboembolism
– Less bleeding
• Compared to SQ UFH
– Similar outcomes

34. Fondaprinux
• Subcutaneous administration
• Similar outcomes when compared to IV UFH
• Contraindicated in patients with severe renal
failure

35. Warfarin
• Started after administration of heparin (or
heparin like agent)
• Adjusted dose to INR 2.0-3.0

36. Duration of anticoagulation
• First Episode
– Reversible  3 months
– Unprovoked  indefinite (if bleeding risk
acceptable)
• Recurrent PE
– Indefinite if risk of bleeding acceptable

37. New Anticoagulants- Rivaroxaban
• Factor Xa Inhibitor
• FDA approved for
– non valvular A fib,
– postop thromboprophylaxis hip and knee replacement
– Treatment of DVT
• Non inferior to Warfarin in Einstein PE study 2012
EINSTEIN-PE Study
NEJM 2012

38. Rivaroxaban
• Given as 15mg PO dose BID for 3 weeks then
20mg daily
• Doesn’t require monitoring
• Good safety profile (less bleeding than with
warfarin)

39. Dabigatran
• Oral thrombin inhibitor
• FDA approved for non valvular Atrial Fibrillation
• Studied in Re-cover trial for DVT (not PE)
• Non inferior to warfarin
• Good safety profile
Schulman et al
NEJM 2009

40. Thrombolysis
• Indications
– Massive PE (SBP <90 for >15mins)
• Controversial Indication
– Severe hypoxemia
– Large thrombus burden
– RV dysfunction
• ECG, Cardiac Enzyme Elevation, Echocardiography
– RV thrombus in transit
– Saddle Embolus

41. Contraindications
• Absolute Contraindications
– Intracranial neoplasm
– Recent (<3 months) intracranial surgery or trauma
– recent (<3 months) ischemic stroke
– h/o hemorrhagic stroke
– Active or recent bleeding

42. • Relative Contraindications
– BP > 180 systolic
– H/o ischemic stroke
– Recent (<4 weeks) internal bleeding
– Thrombocytopenia

43. Thrombolytic Agents
• Tissue Plasminogen Activator – tPA
– Alteplase
– IV drip 100mg over 2 hours
• Streptokinase
– IV drip 250,000 units over 30mins
– Followed by 100,000u/hr for 24hrs
• Urokinase

44. Side Effects of thrombolysis
• Bleeding (9%)
– Intracranial hemorrhage (3%)
• Allergic Reactions – Streptokinase
• Hypotension - Streptokinase

45. Real Life Case
• 52 yo male with cardiomyopathy (EF10%),
• PH of DVT/PE in 2005, Gout
• Presented with worsening shortness of breath
• Has stable ET at 2-3 blocks
• HR 69, BP 105/79
• 2/6 systolic murmur
• Trace LE edema

47. Echocardiography
• Normal echo

48. Before thrombolysis After thrombolysis

49. Surgical Embolectomy
• Experienced Surgeon
• Requires cardiopulmonary bypass
• Indicated as an alternative to thrombolysis or
when thrombolysis is contraindicated

51. Inferior Vena Cava Filter
• “Filter out” large emobli
from the pelvis, lower
extremities
• Inserted percutaneously
• Indicated for patients
who have
contraindications to
anticoagulation

52. THANK YOU