Pulmonary Embolism

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Contraindications• Intracranial neoplasm

• Recent (ie, <2 months) intracranial surgery or trauma

• Active or recent internal bleeding during the prior six months

• History of a hemorrhagic stroke

• Bleeding diathesis

• Severe uncontrolled hypertension (ie, systolic blood pressure >200 mmHg or diastolic blood pressure >110 mmHg)

• Nonhemorrhagic stroke within the prior two months

• Surgery within the previous ten days

• Thrombocytopenia (ie, <100,000 platelets/mm3)

- Chest 2012

Indication(s)

TPA in PE

• Not proven to have mortality benefit– Long Term Data Lacking– “quality of evidence regarding mortality and recurrent PE is low because of risk of

bias, serious imprecision, and suspected publication bias.”- CHEST 2012.

• Leads to early hemodynamic improvement, but at increased risk of major bleeding– Systemic TPA suggested acute PE with or at high risk

of developing hypotension (eg, systolic BP < 90 mm Hg) without high bleeding risk (Grade 2C)

– In most patients with acute PE not associated with hypotension, we recommend against systemically administered thrombolytic therapy (Grade 1C)

•Methods: 121 patients randomly assigned to ½ dose v anticoagulation

•Found: •Lower pulmonary hypertension rate in TG (57v16 percent)•Faster resolution of pulmonary hypertension TG•Lower pA systolic pressures at 28 months in TG (43v28mmHg)  •Similar rates of bleeding and mortality

•Weakness:•Small sample size

Pulmonary Embolism

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• PE estimated incidence of 112 in 100,000– Unclear incidence of Massive PE

• PFO estimated prevalence ~25% of population

Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171(9):831.

Cleveland Clinic. http://my.clevelandclinic.org/heart/disorders/congenital/pfo.aspx

Massive PE + ASD

• Case reports suggest may act as pressure relief valve preventing complete homodynamic collapse– Unfortunately still associated with stroke and

refractory hypoxemia

• Special population? – Does R-> L shunt limit efficacy of therapy?– Increased risk of intracranial hemorrhage?

Moua T, Wood KE, Atwater BD, Runo JR. Major pulmonary embolism and hemodynamic stability from shunting through a patent foramen ovale. South Med J. 2008 Sep;101(9):955-8.

Murdoch H, Loveday E, Soar J. Effectiveness of thrombolysis for massive pulmonary embolism with an atrial septal defect. Resuscitation. 2011 Jul;82(7):960-1.