Pulmonary Embolism: From Acute PE to Chronic Complications (Respiratory Medicine)

This book is a comprehensive guide to the diagnosis and management of all stages of pulmonary embolism, starting with acute and ending with chronic thromboembolic pulmonary hypertension. Acute pulmonary embolism (PE) is responsible for 150-250,000 hospitalizations and 60-100,000 deaths each year in the United States, making it the third most common cause of cardiovascular death. Acute PE spans a wide spectrum of clinical outcomes mainly based on the right ventricle’s (RV) capacity to tolerate strain. There have been many recent advances in the field of PE, including guidelines on classification and risk stratification, anticoagulation, as well as evolving areas in treatment options and follow up. The text begins with a review of the epidemiology and risk factors for PE. Chapters then delve into reviewing the decision pathways based on PE severity and treatment options, including the use of oral anticoagulation, systemic and catheter-directed thrombolysis, mechanical and surgical thrombectomy, and hemodynamic support with extracorporeal membrane oxygenation. The text then focuses on post-PE complications such as post-PE syndrome, chronic thromboembolic disease, and chronic thromboembolic pulmonary hypertension (CTEPH). This is an ideal guide for providers of lung health, including pulmonary and critical care physicians, cardiologists, thoracic and cardiovascular surgeons. Physician-trainees, physician assistants, nurses and respiratory therapists with interest in pulmonary disorders, cardiovascular disease, pulmonary embolism, critical care or pulmonary hypertension will also find great value in this comprehensive guide. Contents 5 Contributors 7 Pulmonary Embolism 3 Epidemiology of Pulmonary Embolism 9 Introduction 9 Incidence and Prevalence of PE 10 Age, Gender, and Ethnicity 11 PE-Related Mortality 11 Impact of VTE Risk Factors on PE Epidemiology 12 Conclusion 16 References 16 PE Diagnosis 21 Approach to Patients with Suspected Pulmonary Embolism 21 Clinical Prediction Rules 21 D-Dimer 23 Clinical Use of Prediction Scores and Drawbacks 23 Imaging Studies 23 Chest Radiograph (CXR) 23 Electrocardiogram 25 Echocardiography 26 Computed Tomography Pulmonary Angiography (CTA) 28 Pulmonary Angiography 31 Ventilation-Perfusion (V/Q) Scan 32 Ultrasonography 34 Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiogram (MRA) 35 Conclusion 36 References 36 Risk Stratification of Acute PE 40 Introduction 40 Classification of Acute PE 40 Risk Stratification of Acute PE 42 Clinical Scoring Systems 42 Biomarkers 43 Troponin 43 B-Type Natriuretic Peptide 44 Right Ventricular Imaging 44 Echocardiogram 44 Computed Tomographic Angiography (CTA) 46 Integrated Risk Stratification 47 Summary 48 References 48 Bleeding Risk Considerations Prior to Initiation and Duration of Anticoagulation Therapy for the Treatment of Venous Thromboembolism 51 Introduction 51 Incidence of Bleeding 52 Incidence of Major Bleeding During Initial Anticoagulation with Heparin, LMWH, or Fondaparinux 52 Incidence of Major Bleeding During the First Three Months of Treatment with a Vitamin K Antagonist 53 Incidence of Major Bleeding with the Direct Oral Anticoagulants 53 Considerations Prior to Initiation of Anticoagulation Therapy 54 Bleeding Risk Considerations Prior to Initiation of Anticoagulant Therapy 54 Incidence of Major Bleeding Associated with Thrombolytic Therapy 58 Summary 60 References 60 Treatment for Pulmonary Embolism: Anticoagulation Selection and Duration 63 Introduction 63 Historical Perspective 64 Overview of Anticoagulants 64 Parenteral Agents 69 Heparinoids and Fondaparinux 69 Direct Thrombin Inhibitors (DTIs) 69 Oral Anticoagulants 70 Vitamin K Antagonists 70 Direct-Acting Oral Anticoagulants (Apixaban, Edoxaban, Rivaroxaban, and Dabigatran) 70 Treatment Paradigms 71 LMWH Trials 71 Fondaparinux Trials 72 DTI Trials 72 Argatroban 72 Bivalirudin 72 DOAC Trials 72 Extended Therapy 74 Special Populations 75 Pregnancy and Lactation 75 Cancer 76 Antiphospholipid Syndrome (APLS) 76 Heparin-Induced Thrombocytopenia (HIT) 77 Renal Impairment 77 Hepatic Impairment 78 Obesity 79 Pediatrics 81 Anticoagulation Reversal 81 Future Directions 83 Conclusion 83 References 84 Indications for Systemic Thrombolysis Over Anticoagulation 90 Introduction and Overview 90 Thrombolytic Agents 91 Alteplase 92 Streptokinase 93 Urokinase 93 Other Agents 94 Adverse Reactions 94 Summary 95 Contraindications to Thrombolytics 95 Indications for Thrombolysis Based on Risk Stratification of Pulmonary Embolism 97 Classification and Risk Stratification 97 Use of Thrombolytic Therapy in High-Risk Pulmonary Embolism 98 Use of Thrombolytic Therapy in Intermediate-Risk Pulmonary Embolism 99 Use of Thrombolytic Therapy in Low-Risk Pulmonary Embolism 100 Other Considerations 100 Low-Dose Thrombolysis 100 Catheter-Directed Thrombolysis 101 Cardiopulmonary Arrest 101 Impact of Thrombolysis on Long-Term Outcomes 102 Mortality 102 Hemodynamics and RV Function 102 Venous Thromboembolism Recurrence 103 Bleeding 103 Summary 103 References 104 Endovascular Techniques in the Treatment of Acute PE 108 Introduction to Catheter-Directed Therapy 108 Role and Rationale for Catheter-Directed Therapy 108 Evidence for Catheter-Directed Therapy 110 Contraindications to Catheter-Directed Therapy 112 Preparation for Catheter-Directed Therapy 112 Procedure Walkthrough 113 Periprocedural IVC Filter Placement 116 Follow-Up Care 116 References 116 Role of Surgical Embolectomy and ECMO in PE 119 The History of Surgical Therapy for Acute Pulmonary Emboli 119 SPE and Outcomes in the Modern Era 120 Indications for Surgical Pulmonary Embolectomy 123 Surgical Procedure 123 SPE as First-Line Therapy 124 VA-ECMO in PE 125 Conclusion 127 References 127 Inferior Vena Cava Filters in Venous Thromboembolism 130 Introduction and Background 130 Types of IVC Filters 131 Indications for Filter Placement 131 Evidence-Based Literature Review 133 Complications of IVC Filters 135 Future Directions 137 References 137 Multidisciplinary PE Response Team Development and Implementation 141 Background 141 PERT 142 Review of Published PERT Data 147 PERT Consortium 151 References 152 Post-PE Management 155 Introduction 155 The Outpatient Clinic Setting – Follow-Up After Acute PE 156 Symptoms 156 History: The Initial Event 158 Risk Factors for VTE 158 Assessment of Bleeding Risk 159 Medication Review 159 Physical Examination and Laboratory Testing 160 Physical Examination 160 Laboratory Testing 161 Anticoagulation Post-Pulmonary Embolism 161 Drug Interactions 161 Renal and Hepatic Insufficiency 162 Obesity and Anticoagulants 162 Anticoagulant Absorption and Bariatric Surgery 163 Cancer and Anticoagulants 163 Duration of Anticoagulation: Persisting Risk of VTE and Thrombophilia Testing 164 Duration of Anticoagulation 164 Thrombophilia Testing 167 Screening for Malignancy 170 Other Aspects of Post-Pulmonary Embolism Management 170 Oxygen Requirement Post-PE 170 Inferior Vena Caval (IVC) Filters 170 Post-Thrombotic Syndrome (PTS) 171 Post-PE Rehabilitation 171 Management of Recurrent VTE 171 Post-PE Dyspnea 172 Post-PE Diagnostic Imaging 175 Long-Term Survival and VTE Recurrence: What to Tell the Patient 176 Conclusions 177 References 178 Epidemiology and Diagnosis of Chronic Thromboembolic Pulmonary Hypertension 183 Background 183 Epidemiology of CTEPH 184 Risk Factors for CTEPH 186 Screening for CTEPH 186 Diagnosis of CTEPH 188 Symptoms and Exam 190 EKG 191 Chest X-Ray 191 Pulmonary Functions Tests 191 Echocardiography 191 Ventilation/Perfusion Scintigraphy (VQ) 192 Single Photon Emission Computed Tomography (SPECT-VQ) 192 Computed Tomography Pulmonary Angiography (CTPA) 193 Dual-Energy CT 194 Digital Subtraction Angiography 196 Magnetic Resonance Angiography (MRA) 197 Right Heart Catheterization 197 Cardiopulmonary Exercise Testing 198 Mimickers of CTEPH 198 Conclusions 199 References 200 Medical, Endovascular, and Surgical Treatment of CTEPH 205 Introduction 205 Surgical Treatment 206 Balloon Pulmonary Angioplasty 209 Medical Therapy 211 Conclusion 213 References 213 Index 217