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Dr. dr. Azhari Gani SpPD-KKV, FINASIM, FCIC


Pengurus Besar Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PB PAPDI)
13 -15 Oktober 2017

The true incidence of PE is unknown and is

suspected to be underestimated
It is estimated to be between 0.5% to 3% in
the general population
Mortality from PE is estimated to be 0.1%
alterations in blood flow

endothelial injury or dysfunction.

Nisio MD, Nick VE, Buller HR. Deep vein thrombosis and pulmonary embolism. The lancet.2016:1-14
Clinical and environmental risk factors
Older age
Active cancer
Antiphospholipid syndrome
Oestrogen therapy
Pregnancy or puerperium
Personal or family history of venous thromboembolism
Autoimmune and chronic inflammatory diseases (eg, inflammatory bowel disease)
Heparin-induced thrombocytopenia
Vascular damage
Trauma or fracture
Central venous catheter or pacemaker
Venous stasis or immobilisation
Hospitalisation for acute medical illness
Nursing-home residence
Long-hour travel for more than 4 h
Paresis or paralysis
Heritable risk factors
Factor V Leiden
Prothrombin 20210G A mutation
Antithrombin deficiency
Protein C deficiency
Protein S deficiency
Non-0 blood group
Wilbur J, Shian B. Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism. Am Fam Physician.2012;86:913-9.
Pulmonary embolism
Presents with acute chest pain.
Breathlessness with shock.
Cough & hemopysis.
May be fatal.
Diagnosis: Chest X-Ray
Usually abnormal, but non-specific
Study of 2,322 patients with PE:
Cardiac enlargement (27%)
Normal (24%)
Pleural effusion (23%)
Elevated hemidiaphragm (20%)
Pulmonary artery enlargement (19%)
Atelectasis (18%)
Parenchymal pulmonary infiltrates (17%)

Chest Radiographs in Acute Pulmonary Embolism: Results From the International Cooperative
Pulmonary Embolism Registry. Chest July 2000 118:3338; 10.1378/chest.118.1.33
Radiographic Signs Hamptons Hump
Diagnosis: ECG
Usually non-specific ST/T waves changes
and tachycardia
RV strain patterns suggest severe PE
Inverted T waves V1-V4

QR in V1

Incomplete RBBB

Pulmonary Embolism
Clinical Decision Rules

Models for assessing clinical Probability of

Pulmonary Embolism
Wells Criteria
Geneva Score
Wells Score
Clinical symptoms of DVT (leg Traditional clinical probability assessment
swelling, pain with palpation) (Wells criteria)

Other diagnosis less likely than High >6.0

pulmonary embolism
Moderate 2.0 to 6.0
Heart rate >100 1.5
Low <2.0
Immobilization (3 days) or surgery
in the previous four weeks Simplified clinical probability assessment
(Modified Wells criteria)
Previous DVT/PE 1.5
PE likely >4.0
Hemoptysis 1.0
Malignancy 1.0 PE unlikely 4.0
Simplified Geneva Score
Variable Score
Age >65 1
Previous DVT or PE 1
Surgery or fracture within 1 month 1
Active malignancy 1
Unilateral lower limb pain 1
Hemoptysis 1
Pain on deep vein palpation of lower limb
and unilateral edema
Heart rate 75 to 94 bpm 1
Heart rate greater than 94 bpm +1
Score of less than 2 is low probablility for PE, score of less than 2 plus a negative D-
dimer results in a likelihood of PE of 3%
Diagnostic tests

Elevated in thrombosis, malignancy, pregnancy, elderly,

hospitalized patients
Role in low or moderate probability for PE
Normal results can rule out PE

Estimated 3 month risk of thromboembolism with

negative D-dimer is 0.14%

Role in high probability patients proceed to CT,
negative d-dimer can miss up to 15% of patients in this
Advanced Diagnostics
Pulmonary scintigraphy
Pulmonary angiography.
Pulmonary Scintigraphy
Aids in diagnosis of PTE but not definitive.
Two types- ventilation and perfusion scans.
Ventilation-Perfusion Scans

Useful if Normal (negative predictive value of 97%)

Also useful if High probability (positive predictive value of
85 to 90%)
Unfortunately, only diagnostic in 30 to 50% of patients
Normal Human Perfusion Scan
Abnormal Human Perfusion Scan
Spiral CT
Direct visualization of emboli.
Both parenchymal and mediastinal structures
can be evaluated.
Offers differential diagnosis in 2/3 of cases with
a negative scan.
Dye load and large radiation dose
Optimally used when incorporated into a
validated diagnostic decision tree
CT Agiogram
Pulmonary Angiography in PE

The gold standard

A negative pulmonary angiogram excludes clinically
relevant PE.
The risk of embolization in patients with a negative
angiogram is extremely low
Pulmonary Angiography
Diagnostic Algorithm

0.5% (all non fatal) 1.3%

Oxygen therapy.
Heparinization 200-300 units/kg
subcutaneously every 8 hours.
Streptokinase or TPA.
Mechanical ventilation.
Long term- warfarin therapy.
Jose Luis Zamorano, Stephan Achenbach, Helmut Baumgartner, et al. ESC Guidelines on the diagnosis and management of acute pulmonary
embolismweb addenda. 2014: at
Clotting times- want to maintain PTT at 1.5-
2.5 times normal or and ACT at 1.2-1.4
times normal.
Serial arterial blood gas analysis.
Respiratory rate.
Central venous pressure.
All other basic monitoring.
Complications Of Therapy
Hemorrhage most common.
Not predictable.
Protamine therapy indicated with
hemorrhage due to heparin.
Vitamin K or fresh-frozen plasma in
warfarin therapy.
Invasive Treatment PE
Percutaneous embolectomy
Catheter-directed thrombolysis
Clot fragmentation
Surgical Embolectomy
Pulmonary Artery Stenting

Konstantinides S, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D. 2014 ESC Guidelines on the diagnosis and management of acute
pulmonary embolism. European Heart Journal.2014:1-48.
Peter Augustinos, MD; Kenneth Ouriel, MD. Invasive Approaches to Treatment of Venous Thromboembolism. Circulation. 2004;110:27-34.
Catheter Embolectomy & Fragmentation

An alternative in high-risk PE patients when thrombolysis is

absolutely contraindicated or has failed

Kucher N Chest 2007;132:657-663

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