A Case of Pulmonary Thromboembolism

(Dr. K.K. Gupta M.D Associate Professor, Department of Medicine)

A 50 year old women presents to the emergency room with acute onset shortness
of breath, lightheadedness and chest pain. She recently had been to visit her
parents out of country by flight for about 12 hours each way. Two days ago, she
developed mild calf pain and swelling, but she thought that this was not unusual
after having been sitting with her legs dependent for the recent trip. On arrival to
the emergency room, she is noted to be tachypneic and diaphoretic. Her vitals
signs are as follows: blood pressure 86/58 mm Hg, heart rate 114 beats /mins,
respiratory rate 28 breaths /min, oxygen saturation of 92% on room air, weight 84
kg. The lungs are clear bilaterally. Cardiovascular examination shows a regular
tachycardia without murmurs, rub or gallop. There is pain in the right calf with the
dorsiflexion of the foot and the right leg is more swollen when compared to the
left. An arterial blood gas measurement shows a pH of 7.52, PCO​2 ​ 25 mmHg and
PO​2 68
​ mmHg. Kidney and liver function test are normal.

1.) What is the most likely cause in this patient?

a.) Acute Respiratory Distress Syndrome

b.) Myocardial Infarction
c.) Pulmonary Thromboembolism
d.) Pleuritis

2.) Which is the most frequent symptom of this disease?

a.) Syncope
b.) Pleuritic pain
c.) Dyspnea
d.) Haemoptysis

3.) What is the most frequent ECG finding in this diease?

a.) S1Q3T3 pattern
b.) P pulmonale
c.) Sinus tachycardia
d.) Right axis deviation

4.) What is best investigation to be done in this patient for diagnosis?

a.) D- Dimer Assay
b.) Multidetector CT angiography
c.) Doppler Ultrasound
d.) ECG

5.) False positive D-Dimer assay is seen in all except?

a.) Pneumonia
b.) Myocardial Infarction
c.) Pregnancy
d.) DVT

6.) What is the treatment of choice in case of Massive Pulmonary Embolism

in shock?
a.) Low molecular weight heparin
b.) Thrombolytic therapy
c.) Aggressive fluid resuscitation
d.) Anticoagulation AND Thrombolytic therapy
 EXPLANATORY ANSWERS

1)Answer c

Explanation​- Venous thromboembolism (VTE), which

encompasses deep venous thrombosis and pulmonary embolism. .
For patients who have DVT, the most common history is a cramp
in the lower calf that persists for several days and becomes more
uncomfortable as the time progress.

CLINICAL DECISION RULE FOR ​pulmonary embolism :

CLINICAL VARIABLE SCORE

1​. SIGN AND SYMPTOMS OF DVT 3.0
2. ALTERNATIVE DIAGNOSIS LESS 3.0
LIKELY THAN PE
3. HEART RATE >100 1.5
4. EMMOBILIZATION >3 DAYS; 1.5
surgery within 4 weeks
5.PRIOR PE/ DVT 1.5
6. HEMOPTYSIS 1.0
7. CANCER 1.0
HIGH CLINICAL LIKELYHOOD OF PE IF POINT SCORE EXCEEDS 4.

In​ this patient 1,2,3, point present and so her score is 3+3+1.5 = 7.5, which suggest
PULMONARY THROMBOEMBOLISM ​is the most likely diagnosis.

2)Answer c

EXPLANATION- ​Dyspnea is the most common symptom of PE, and tachypnea is

the most common sign. Dyspnea, syncope, hypotension, or cyanosis indicates a
massive PE, whereas pleuritic pain, cough, or hemoptysis often suggests a small
embolism situated distally near the pleura.

3)Answer c

EXPLANATION-​ ​Electrocardiogram ​The most frequently cited abnormality, in

addition to sinus tachycardia, is the S1Q3T3 sign: an S wave in lead I, aQ wave in
lead III, and an inverted T wave in lead III . S1Q3T3 sign is relatively specific sign
to PE but not sensitive.

4)Answer b

EXPLANATION- ​Chest CT ​ with intravenous contrast is the principal imaging

test for the diagnosis of PE.
Multidetector-row spiral CT acquires all chest images with ≤1 mm of resolution
during a short breath hold. This generation of CT scanners can image small
peripheral emboli. Sixth-order branches can be visualized.

Venous ultrasonography
loss of vein compressibility as the primary criterion for DVT.

Chest roentgenography:
​A normal or nearly normal chest x-ray often occurs in PE. abnormalities include
focal oligemia (​Westermark’s sign),​ a peripheral wedged-shaped density
above the diaphragm (​Hampton’s hump),​ and an enlarged right
descending pulmonary artery (​Palla’s sign​).
5)Answer d

EXPLANATION-​ ​The D-dimer assay is a useful ‘rule out’ test. More than 95%
patient having normal D-DIMER (​<​ 500 ng/ml) do not have Pulmonary
embolism.The D-dimer assay is not specific. False positive D-dimer assay is seen
in myocardial infarction,pneumonia,sepsis,cancer,post operative state and those in
second and third trimester of pregnancy.

6)Answer d

EXPLANATION- ​TREATMENT OF PE

PRIMARY THERAPY​ c​ onsists of clot dissolution with thrombolysis or removal

of PE by embolectomy.
SECONDARY PREVENTION​ Anticoagulation with heparin and warfarin
or placement of an inferior vena caval filter.
​FIBRINOLYSIS
The preferred fibrinolytic regimen is 100 mg of recombinant tissue plasminogen
activator (tPA) administered as a continuous peripheral intravenous infusion over 2
hours. Patients appear to
respond to fibrinolysis for up to 14 days after the PE has occurred.
Contraindications are intracranial disease recent surgery, and trauma.
 REFERENCES:

Longo DL ,Fauci AS, Kasper DL, Hauser SL, ,Jameson JL, et al.,
editors. Harrison’s principles of internal medicine. 18​th ​ed. New York:
McGraw Hill; 2012. p. 2170-2177

Venous thromboembolism (VTE), which encompasses deep venous

thrombosis (DVT) and pulmonary embolism (PE),
Risk factors​ include​ ​Thrombophilia (factor V Leiden, prothrombin gene mutation,
Hyperhomocysteinemia, Antiphospholipid antibody syndrome, cancer, systemic arterial
hypertension, chronic obstructive pulmonary disease, long-haul air travel, air pollution, obesity,
cigarette smoking, eating large amounts of red meat,oral contraceptives, pregnancy,

Dyspnea is the most common symptom of PE, and tachypnea is the most common sign.
Dyspnea, syncope, hypotension, or cyanosis indicates a massive PE, whereas pleuritic pain,
cough, or hemoptysis often suggests a small embolism situated distally near the pleura.

INVESTIGATIONS
Nonimaging diagnostic modalities
Blood tests :
The quantitative ​plasma d-dimer enzyme-linked immunosorbent
assay (ELISA) r​ ises in the presence of DVT or PE indicates endogenous thrombolysis. The
sensitivity of the d-dimer is >80% for DVT and >95% for PE. The d-dimer assay is not
specific. Levels increase in patients with myocardial infarction, pneumonia, sepsis, cancer, and
the postoperative state and those in the second or third trimester of pregnancy.
Elevated cardiac biomarkers:
 ​ erum troponin and plasma heart type fatty acid–binding protein levels increase because of RV
S
microinfarction. Myocardial stretch results in elevation of brain natriuretic peptide or
NT-pro-brain natriuretic peptide.
Electrocardiogram ​The most frequently abnormality is sinus tachycardia, S1Q3T3 sign: an S
wave in lead I, aQ wave in lead III, and an inverted T wave in lead III .
Noninvasive imaging modalities
Venous ultrasonography
loss of vein compressibility as the primary criterion for DVT.
Chest roentgenography:
​A normal or nearly normal chest x-ray often occurs in PE. abnormalities include focaloligemia
(​Westermark’s sign),​ a peripheral wedged-shaped density
above the diaphragm (​Hampton’s hump),​ and an enlarged right
descending pulmonary artery (​Palla’s sign​).
Chest CT
is the principal imaging test for the diagnosis of PE
Multidetector-row spiral CT acquires all chest images with ≤1 mm of resolution during a short
breath hold. This generation of CT scanners can image small peripheral emboli. Sixth-order
branches can be visualized
Lung scanning
a second-line diagnostic test for PE, used mostly for patients who cannot tolerate intravenous
contrast. Small particulate aggregates of albumin labeled with a gamma-emitting radionuclide
are injected intravenously and are trapped in the pulmonary capillary bed. The perfusion scan
defect indicates absent or decreased blood flow, possibly due to PE.
Magnetic resonance (MR) (contrast-enhanced)
should be considered for suspected VTE patients with renal insufficiency or contrast dye allergy.
MR pulmonary angiography may detect large proximal PE but is not reliable for smaller
segmental and subsegmental PE.
Echocardiography ​ is ​not a​ reliable diagnostic imaging tool for acute PE
Invasive diagnostic modalities
Pulmonary angiography
is reserved for patients with technically unsatisfactory chest CTs and those in whom an
interventional procedure such as catheter-directed thrombolysis or
embolectomy is planned.

TREATMENT

PRIMARY THERAPY​ c​ onsists of clot dissolution with thrombolysis or removal

of PE by embolectomy.
SECONDARY PREVENTION​ Anticoagulation with heparin and warfarin
or placement of an inferior vena caval filter
FIBRINOLYSIS
The preferred fibrinolytic regimen is 100 mg of recombinant tissue plasminogen activator (tPA)
administered as a continuous peripheral intravenous infusion over 2 hours. Patients appear to
respond to fibrinolysis for up to 14 days after the PE has occurred. Contraindications are
intracranial disease recent surgery, and trauma.
ANTICOAGULATION
It do ​not d​ irectly dissolve thrombus that already exists.
Unfractionated Heparin
an initial bolus of 80 U/kg, followed by an initial infusion rate of 18/kg per h.
advantage of UFH is its short half-life. Disadvantage risk of developing heparin-induced
thrombocytopenia.
Low-Molecular-Weight Heparins ​exhibit less binding to plasma proteins and
have greater bioavailability, a more predictable dose response, and a longer half-life than does
UFH. No monitoring or dose adjustment is needed. enoxaparin and dalteparin. ​Enoxaparin ​is
approved as a bridge to warfarin for VTE. ​Dalteparin ​is also approved as monotherapy without
warfarin for symptomatic
Fondaparinux ​Fondaparinux, an anti-Xa pentasaccharide, is administered as a once-daily
subcutaneous injection. Patients weighing <50 kg receive 5 mg, patients weighing 50–100 kg
receive 7.5 mg, and patients weighing >100 kg receive 10 mg.
It does not cause heparin-induced thrombocytopenia.
Warfarin
is initiatedin a dose of 5 mg. Doses of 7.5 or 10 mg can be used in obese
The target INR is usually 2.5, with a range of 2.0–3.0
INFERIOR VENA CAVAL (IVC) FILTERS ​indications are (1) active bleeding that
precludes anticoagulation and (2) recurrent venous thrombosis despite intensive anticoagulation.