acute venous pulmonary embolism restore cardiopulmonary hemodynamics avoid recurrence avoid chronic...
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Acute Venous Pulmonary EmbolismAcute Venous Pulmonary Embolism
•Restore cardiopulmonary hemodynamics
•Avoid recurrence
•Avoid chronic thromboembolic pulmonary hypertension
•Restore cardiopulmonary hemodynamics
•Avoid recurrence
•Avoid chronic thromboembolic pulmonary hypertension
Goals of TherapyGoals of Therapy
…with their associated morbidity and mortality
…with their associated morbidity and mortality
Pulmonary EmbolismPulmonary Embolism
Chronic Thromboembolic Pulmonary HypertensionChronic Thromboembolic Pulmonary Hypertension
After First Episode of PEAfter First Episode of PE
6 months
1.0%
6 months
1.0%
1 year
3.1%
1 year
3.1%
2 years
3.8%
2 years
3.8%CTPHCTPH
Pengo V, et alNEJM 2004;350:2257Pengo V, et alNEJM 2004;350:2257
Pulmonary EmbolismPulmonary Embolism
Recommendations for AnticoagulationRecommendations for Anticoagulation
Similar to DVTSimilar to DVT
•Rapid improvement of arteriogram and lung scans (P<.05)
•Reduced PA and R arterial pressure (P<.05)
•No difference in overall mortality (study not designed to detect mortality difference)
•Less mortality with massive PE
•Rapid improvement of arteriogram and lung scans (P<.05)
•Reduced PA and R arterial pressure (P<.05)
•No difference in overall mortality (study not designed to detect mortality difference)
•Less mortality with massive PE
NIH Trials: Early ResultsNIH Trials: Early ResultsNIH Trials: Early ResultsNIH Trials: Early Results
CirculationCirculation 1973; 39: S1973; 39: SIIII-1-1JAMAJAMA 1974; 229:1606-131974; 229:1606-13CirculationCirculation 1973; 39: S1973; 39: SIIII-1-1JAMAJAMA 1974; 229:1606-131974; 229:1606-13
Thrombolytic Rx for PEThrombolytic Rx for PE
Thrombolytic Rx for PEThrombolytic Rx for PE
•Improved pulmonary cap blood vol (P<.001)
•Improved O2 diffusing capacity (P<.05)
•Reduced PA pressure @ rest and exercise (P<.05)
•Reduced PVR @ rest and exercise (P<.05)
•Less recurrent DVT and PE (P<.05)
•Less CHF (NYHA II-IV) (P<.05)
•Improved pulmonary cap blood vol (P<.001)
•Improved O2 diffusing capacity (P<.05)
•Reduced PA pressure @ rest and exercise (P<.05)
•Reduced PVR @ rest and exercise (P<.05)
•Less recurrent DVT and PE (P<.05)
•Less CHF (NYHA II-IV) (P<.05)
NIH Trials: Long-Term ResultsNIH Trials: Long-Term ResultsNIH Trials: Long-Term ResultsNIH Trials: Long-Term Results
CirculationCirculation 1973; 39: S1973; 39: SIIII-1-1JAMAJAMA 1974; 229:1606-131974; 229:1606-13CirculationCirculation 1973; 39: S1973; 39: SIIII-1-1JAMAJAMA 1974; 229:1606-131974; 229:1606-13
Jerjes-Sanchez C, et alJ Thromb Thrombolyis 1995; 2:227Jerjes-Sanchez C, et alJ Thromb Thrombolyis 1995; 2:227
100% (4/4)100% (4/4)0% (0/4)0% (0/4)Mortality*Mortality*
Heparin AloneHeparin AloneSK + HeparinSK + Heparin
*Ethics committee terminated trial!*Ethics committee terminated trial!
Massive Pulmonary EmbolismMassive Pulmonary EmbolismLytic Rx vs. AnticoagulationLytic Rx vs. Anticoagulation
Randomized TrialRandomized Trial
Hemodynamic OutcomeHemodynamic OutcomeHemodynamic OutcomeHemodynamic Outcome
0.060.069%9%00Recurrent PE (14 days)Recurrent PE (14 days)
0.00010.00011.5%1.5%14.6%14.6%Improved Pulm. Per.Improved Pulm. Per.
0.010.0126 cm226 cm223.8 cm223.8 cm2 End diastolic area End diastolic area
17%17%2%2% Worse Worse
0.0050.00517%17%39%39% Improved Improved
Right Vent. Fct. (24 hrs)Right Vent. Fct. (24 hrs)
P-valueP-valueHeparinHeparinrt-PArt-PA
Goldhaber SZGoldhaber SZLancetLancet 1993 1993Goldhaber SZGoldhaber SZLancetLancet 1993 1993
Lytic Rx for PE: Randomized TrialLytic Rx for PE: Randomized Trial
Lytic Rx vs. AnticoagulationLytic Rx vs. Anticoagulation
•Multicenter registry•Thrombolytic Rx vs. anticoagulation•30-day mortality lower in patients receiving
lytic Rx (4.7 vs. 11.1, P=0.016)•Primary lysis was only independent
predictor of survival (multivariate analysis)
•Multicenter registry•Thrombolytic Rx vs. anticoagulation•30-day mortality lower in patients receiving
lytic Rx (4.7 vs. 11.1, P=0.016)•Primary lysis was only independent
predictor of survival (multivariate analysis)
Konstantinides S, et alKonstantinides S, et alCirculationCirculation 1997 1997Konstantinides S, et alKonstantinides S, et alCirculationCirculation 1997 1997
Pulmonary EmbolismPulmonary Embolism
Pre-RxPre-RxPre-RxPre-Rx
Pulmonary EmbolismPulmonary Embolism
Pre-RxPre-RxPre-RxPre-Rx
Pulmonary EmbolismPulmonary Embolism