Diagnosis and treatment of acute pulmonary embolism in 2010

Česká verze

Authors: J. Widimský
Authors place of work: Klinika kardiologie IKEM Praha, přednosta prof. MU Dr. Jan Kautzner, CSc., FESC
Published in the journal: Vnitř Lék 2011; 57(1): 5-21
Category: Slavnostní přednáška

Summary

Diagnostic approaches in acute pulmonary embolism include evaluation of clinical likelihood, D-dimers, echocardiography and spiral CT angiography and pulmonary scintigraphy. Determination of D-dimers is only meaningful in patients with low or intermediate clinical likelihood. It is safe not to initiate anticoagulation treatment (or to discontinue such treatment) in patients with low clinical likelihood of acute pulmonary embolism and negative D-dimer test (only if methods with 99–100% sensitivity are used). Duplex sonography and pulmonary scintigraphy are only necessary at the centres with a first generation spiral CT and not those with multidetector devices. Investigations in normotensive patients should include echocardiography that should also include assessment of the right ventricular function using echocardiography and determination of biomarkers of pulmonary embolism. Right ventricular dysfunction together with elevated troponins identifies a normotensive group at an increases risk. Highly sensitive troponin T (hsTnT) appears to be particularly valuable. Echocardiography reading might the decisive factor for treatment initiation in patients with massive acute pulmonary embolism. Negative or unclear echocardiography finding warrants spiral CT angiography (CTA). Ventilation/perfusion scan or pulmonary arteriography are recommendable in patients with unclear CTA finding and patients with high clinical likelihood of pulmonary embolism and negative CTA finding. A combination of CTA and CTV also appears useful as it increases the overall sensitivity of the investigation and enables imaging of pelvic veins. Thrombolytic treatment is indicated in haemodynamically unstable patients, patients with a high risk of a massive pulmonary embolism associated with cardiogenic shock or hypotension (systolic pressure below 90 mmHg or a decrease in systolic pressure by > 40 mmHg) or symptoms of acute right-sided heart failure. Thrombolytic treatment is also indicated in pulmonary embolism not receding following heparin treatment, in recurring or expanding pulmonary embolism, in the presence of thrombi in the right heart and in patients with right-to-left shunting through patent foramen ovale. This treatment should also be considered in patients with submassive pulmonary embolism associated with a dysfunction of the right ventricle and increased troponins, and particularly in patients lacking even a relative contraindication of thrombolytic treatment. A thrombolytic of choice is alteplase. Embolectomy or catheterization should be used if thrombolytic treatment is contraindicated or ineffective. Long-term monitoring of massive and submassive acute pulmonary embolism is highly recommended. Low molecular weight heparins or unfractioned heparin or fondaparinux are used in haemodynamically stable patients.

Key words:
diagnostics in pulmonary embolism – treatment of pulmonary embolism – thrombolytic treatment of pulmonary embolism

Zdroje

1. Noboa S, Mottier D, Oger E on behalf of EPI‑ GETBO Study Group. Estimation of a potentially preventable fraction of venous thromboembolism: a community‑based prospective study. J Thromb Haemost 2006; 4: 2720– 2722.

2. Torbicki A, van Beek EJR, Charbonnier B et al. Guidelines on diagnosis and management of acute pulmonary embolism. Eur Heart J 2000; 21: 1301– 1336.

3. Meignan M, Rosso J, Gauthier H et al. Systematic lung scans reveal a high frequency of silent pulmonary embolism in patients with proximal deep venous thrombosis. Arch Intern Med 2000; 160: 159– 164.

4. Morgenthaler TI, Ryu JH. Clinical characteristics of fatal pulmonary embolism in a referral hospital. Mayo Clin Proc 1995; 70: 417– 424.

5. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003; 58: 470– 483.

6. Widimský J, Malý J, Eliáš P et al. Doporučení diagnostiky, léčby a prevence plicní embolie, verze 2007. Doporučení České kardiologické společnosti. Vnitř Lék 2008; 54 (Suppl 1): 1S25– 1S72.

7. Goldhaber SZ, Visani L, DeRosa M et al. for ICOPER. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353: 1386– 1389.

8. Widimský J, Staněk V. Klinická diagnostika hemodynamicky významné plicní embolie. Prakt Lék 1983; 83: 284– 287.

9. Widimský J, Malý J et al. Akutní plicní embolie a žilní trombóza. Praha: Triton 2005, 381 s.

10. Torbicki A et al. Guidelines of the European Society of Cardiology for the Diagnosis and Management of Acute Pulmonary Embolism. Eur Heart J 2008; 29: 2276– 2315.

11. Wells PS, Anderson DR, Rodger M et al. Derivation of a simple clinical model to categorize patients’ probability of pulmonary embolism: increasing the model’s utility with the SimpliRED D‑dimer. Thromb Haemostat 2000; 83: 416– 420.

12. Le Gal G, Righini M, Roy PM et al. Prediction of pulmonary embolism in the emergency department: the revised GENEVA score. Ann Int Med 2006; 144: 165– 171.

13. Pruszcyk P, Bochowicz A, Torbicki A et al. Cardiac troponin T monitoring identifies high‑risk group of normotensive patients with acute pulmonary embolism. Chest 2003; 123: 1947– 1952.

14. Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism. Circulation 2007; 116: 427– 433.

15. Jimenéz D, Uresandi F, Otero R et al. Troponin‑based risk stratification of patients with acute nonmassive pulmonary embolism. Systematic review and meta‑analysis. Chest 2009; 136: 974– 982.

16. Klok FA, Mos IC, Huisman MV. Brain‑type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism. A systematic review and meta‑analysis. Am J Respir Crit Care Med 2008; 178: 425– 430.

17. Kucher N, Printzen G, Goldhaber SZ. Prognostic role of brain natriuretic peptide in acute pulmonary embolism. Circulation 2005; 107: 2545– 2547.

18. Binder L, Pieske B, Olschewski M et al. N‑terminal pro‑brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism. Circulation 2005; 112: 1573– 1579.

19. Dellas C, Puls M, Lankeit M et al. Elevated heart‑type fatty acid‑binding protein levels on admission predict an adverse outcome in normotensive patients with acute pulmonary embolism. J Am Coll Cardiol 2010; 55: 2150– 2157.

20. Lankeit M, Kempf T, Dellas C et al. Growth differentiation factor‑ 15 for prognostic assessment of patients with acute pulmonary embolism. Am J Respir Crit Care Med 2008; 177: 1018– 1025.

21. Lankeit M, Friesen D, Aschoff J et al. Highly sensitive troponin T assay in normotensive patients with acute pulmonary embolism. Eur Heart J 2010; 31: 1836– 1844.

22. Meluzin J, Spinarova L, Bakala J et al. Pulsed Doppler tissue imaging of the velocity of tricuspid annular systolic motion; a new, rapid, and non‑invasive method of evaluating right ventricular systolic function. Eur Heart J 2001; 22: 340– 348.

23. Sanchez O, Trinquart L, Colombet I et al. Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review. Eur Heart J 2008; 29: 1569– 1577.

24. Eliáš P. Úloha výpočetní tomografie v diagnostice plicní embolie. In: Widimský J, Malý J et al. Akutní plicní embolie a žilní trombóza. Praha: Triton 2005: 111– 126.

25. Stein PD, Goodman LR, Gottschalk A et al, for the PIOPED II Investigators. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354: 2317– 2327.

26. Moores LK, Jackson jr. WL, Shorr AF et al. Meta‑analysis: outcomes in patients with suspected pulmonary embolism managed with computed tomographic pulmonary angiography. Ann Intern Med 2004; 141: 866– 874.

27. Van Beek EJ, Reekers JA. The value of pulmonary angiography for the differen tial diagnosis of pulmonary embolism. Eur Radiol 1999; 9: 1310– 1313.

28. Henry JW, Relyea B, Stein PD. Continuing risk of thromboemboli among patients with normal pulmonary angiograms. Chest 1995; 107: 1375– 1378.

29. Quiroz B, Kucher N, Zou KH et al. Clinical validity of a negative computed tomography scan in patients with suspected pulmonary embolism. A systematic review. JAMA 2005; 293: 2012– 2017.

30. Van Belle A, Buller HR, Huisman MV et al for the Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D‑dimer testing, and computed tomography. JAMA 2006; 295: 172– 179.

31. Schoepf UJ, Kucher N, Kipfmueller F et al. Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism. Circulation 2004; 110: 3276– 3280.

32. Lang O. Plicní scintigrafie. In: Widimský J, Malý J et al. Diagnostika, léčba a prevence akutní plicní embolie. Praha: Triton Praha 2005.

33. PISA‑ PED Investigators. Invasive and noninvasive diagnosis of pulmonary embolism. Chest 1995; 107: 33S–38S.

34. Jerjes‑ Sanchez C, Ramirez‑ Rivera A, Garcia M et al. Streptokinase and heparin versus heparin alone in massive pulmonary embolism: a randomised controlled trial. J Thromb Thrombolysis 1995; 2: 227– 229.

35. Wan S, Quinlan DJ, Agnelli G et al. Thrombolysis compared with heparin for the Initial treatment of pulmonary embolism: a meta‑analysis of the randomized controlled trials. Circulation 2004; 110: 744– 749.

36. Konstantinides S, Geibel A, Heusel G et al for the MAnagement strategies And Prognosis of Pulmonary Embolism‑ 3 Trial Investigators (MAPPET‑ 3). N Engl J Med 2002; 347: 1143– 1150.

37. Widimský J. Trombolytická léčba i u normotenzních nemocných, hemodynamicky stabilních s akutní plicní embolií? Interv Akut Kardiol 2005; 4: 66– 68.

38. Widimský J, Malý J. Komentář k novým Doporučením o diagnostice a léčbě plicní embolie Evropské kardiologické společnosti (EKS) (Torbicki et al 2008) ve světle Doporučení diagnostiky, léčby a prevence plicní embolie České kardiologické společnosti – verze 2008. Vnitř Lék 2008; 54: 937– 952.

39. Meneveau N, Schiele F, Metz D et al. Comparative efficacy of a two‑hour regimen of streptokinase versus alteplase in acute pulmonary embolism: Immediate clinical and hemodynamic outcome and one‑year follow‑up. J Am Coll Cardiol 1998; 31: 1057– 1063.

40. Wang CH, Zhai Z, Yang Y et al for the China Venous Thromboembolism (VTE) Study Group. Half the dosage, similar efficacy, less bleeding. The new tissue plasminogen activator regimen for pulmonary embolism? Chest 2010; 136: 254– 264.

41. Meneveau N, Séronde MF, Blonde MC et al. Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest 2006; 129: 1043– 1050.

42. Leacche M, Unic D, Goldhaber S et al. Modern surgical treatment of massive pulmonary embolism: results of 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thor Cardiov Surg 2005; 129: 1018– 1023.

43. Hirsh J, Guyatt G, Albers GW et al. American College of Chest Physicians. Evidence‑based clinical practice guidelines (8th Edition). Executive summary. Chest 2008; 133: (Suppl.): 71S– 105S.

44. Aklog L, Williams ChS, Byrne JG et al. Acute pulmonary embolectomy. Contemporary approach. Circulation 2002; 105: 1416– 1419.

45. Carlbom DJ, Davidson BL. Pulmonary embolism in the critically ill. Chest 2007; 132: 313– 324.

46. Roček M. Léčba plicní embolie katétrem. In: Widimský J, Malý J et al. Akutní plicní embolie a žilní trombóza. Patogeneze, diagnostika, léčba a prevence. Praha: Triton 2005: 241– 252.

47. Kucher N. Catheter embolectomy for acute pulmonary embolism. Chest 2007; 132: 657– 663.

48. Kuo W, Gould M, Louie J et al. Catheter‑ directed therapy for the treatment of massive pulmonary embolism: systematic review and meta‑analysis of modern techniques. J Vasc Interv Radiol 2009; 20: 1431– 1440.

49. Kucher N, Rossi E, De Rosa M et al. Massive pulmonary embolism. Circulation 2006; 113: 577– 582.

50. Smith SB, Geske JB, Jaguare SB et al. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest 2010; 137: 182– 190

51. Malý J. Antikoagulační léčba. In: Widimský J, Malý J et al. Akutní plicní embolie a žilní trombóza. Patogeneze, diagnostika, léčba a prevence. Oraha: Triton 2005, 202– 234.

52. Büller HR, Davidson BL, Decousus H et al for the MATISSE Investigators Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med 2003; 349: 1695– 1702.