Diseases involving the Vasculature

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🌱 來自: Huppert’s Notes

Diseases involving the Vasculature🚧 施工中

Diseases involving the Vasculature

Pulmonary Embolism (PE)

•   Etiology: Virchow’s triad: 1) Endothelial injury, 2) Venous stasis, 3) Hypercoagulability.

•   Risk factors: Older age, malignancy, prior VTE, hypercoagulable state (factor V Leiden mutation, protein C/S deficiency), prolonged bed rest, CHF, obesity, orthopedic surgery, trauma, pregnancy, oral contraceptive pills (OCPs)

•   Diagnosis:

-   EKG: Classic findings: S1Q3T3, RV strain, new incomplete RBBB. Most common finding: Sinus tachycardia

-   CXR: Classic findings (rare): Hampton’s hump, Westermark’s sign. Most common finding: Normal

-   Well’s criteria (most commonly used, but subjective), Geneva Score (objective), PESI score (objective)

•   LOW pre-test probability → D-dimer. D-dimer has high sensitivity (95%), but low specificity (50%) (Christopher study, JAMA 2006)

•   HIGH pretest probability (or +D-dimer) → CT-PE (Stein et al., New Engl J Med 2006)

•   Approach:

-   Assess hemodynamic stability

•   If unstable, manage emergently

•   If stable, assess PE risk (i.e., low risk, intermediate-low risk, or intermediate-high risk)

•   Comment on PE management:

-   Management approach for PE depends on risk stratification, features of individual patients, access to advanced therapies, and local practice

-   Treatment modalities include tPA, catheter-directed thrombolysis, and systemic anticoagulation alone

-   One possible approach stratified by risk classification is described on the next page

•   Classifications and management:

-   Massive PE (high-risk PE)

•   Key features: SBP <90 mmHg, SBP drop >40 mmHg, or shock for >15 minutes despite IVF

•   Treatment: Fibrinolytic (catheter-directed or reduced-dose systemic thrombolysis)

-   Absolute contraindications to tPA: History of hemorrhagic stroke or stroke of unknown origin; ischemic stroke in previous 6 months; central nervous system neoplasm; major trauma, surgery, or head injury in previous 3 weeks; bleeding diathesis; active bleeding

-   Nonmassive PE

•   Intermediate-high risk PE

-   Key features: Acute PE without hypotension but with evidence of abnormal RV function by echocardiography (or a clearly dilated right ventricle by CT pulmonary angiography), plus an elevated troponin and/or brain natriuretic peptide (BNP) level; BOVA score >4 may also be suggestive

-   Treatment: Anticoagulation, plus multidisciplinary discussion about role for fibrinolytics (systemic vs. catheter-directed)

•   Intermediate-low-risk PE

-   Key features: Acute PE without hypotension or evidence of abnormal RV function, but sPESI screen is positive (i.e., at least one of the following: Age >80 yr, cancer, cardiopulmonary disease, HR >110 bpm, SBP <100 mmHg, SpO2 <90%)

-   Treatment: Anticoagulation

•   Low-risk PE

-   Key features: Acute PE with negative sPESI screen (i.e., all of the following: Age <80 yr, no cancer, no cardiopulmonary disease, HR <110 bpm, SBP >100 mmHg, SpO2 >90%)

-   Treatment: Consider outpatient management with direct oral anticoagulants (DOAC); admission may be appropriate based on safety of discharge plan, likelihood of follow-up, etc.