Pulmonary Embolism: From Acute PE to Chronic Complications

Description

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 Contributors Pulmonary Embolism Epidemiology of Pulmonary Embolism Introduction Incidence and Prevalence of PE Age, Gender, and Ethnicity PE-Related Mortality Impact of VTE Risk Factors on PE Epidemiology Conclusion References PE Diagnosis Approach to Patients with Suspected Pulmonary Embolism Clinical Prediction Rules D-Dimer Clinical Use of Prediction Scores and Drawbacks Imaging Studies Chest Radiograph (CXR) Electrocardiogram Echocardiography Computed Tomography Pulmonary Angiography (CTA) Pulmonary Angiography Ventilation-Perfusion (V/Q) Scan Ultrasonography Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiogram (MRA) Conclusion References Risk Stratification of Acute PE Introduction Classification of Acute PE Risk Stratification of Acute PE Clinical Scoring Systems Biomarkers Troponin B-Type Natriuretic Peptide Right Ventricular Imaging Echocardiogram Computed Tomographic Angiography (CTA) Integrated Risk Stratification Summary References Bleeding Risk Considerations Prior to Initiation and Duration of Anticoagulation Therapy for the Treatment of Venous Thromboembolism Introduction Incidence of Bleeding Incidence of Major Bleeding During Initial Anticoagulation with Heparin, LMWH, or Fondaparinux Incidence of Major Bleeding During the First Three Months of Treatment with a Vitamin K Antagonist Incidence of Major Bleeding with the Direct Oral Anticoagulants Considerations Prior to Initiation of Anticoagulation Therapy Bleeding Risk Considerations Prior to Initiation of Anticoagulant Therapy Incidence of Major Bleeding Associated with Thrombolytic Therapy Summary References Treatment for Pulmonary Embolism: Anticoagulation Selection and Duration Introduction Historical Perspective Overview of Anticoagulants Parenteral Agents Heparinoids and Fondaparinux Direct Thrombin Inhibitors (DTIs) Oral Anticoagulants Vitamin K Antagonists Direct-Acting Oral Anticoagulants (Apixaban, Edoxaban, Rivaroxaban, and Dabigatran) Treatment Paradigms LMWH Trials Fondaparinux Trials DTI Trials Argatroban Bivalirudin DOAC Trials Extended Therapy Special Populations Pregnancy and Lactation Cancer Antiphospholipid Syndrome (APLS) Heparin-Induced Thrombocytopenia (HIT) Renal Impairment Hepatic Impairment Obesity Pediatrics Anticoagulation Reversal Future Directions Conclusion References Indications for Systemic Thrombolysis Over Anticoagulation Introduction and Overview Thrombolytic Agents Alteplase Streptokinase Urokinase Other Agents Adverse Reactions Summary Contraindications to Thrombolytics Indications for Thrombolysis Based on Risk Stratification of Pulmonary Embolism Classification and Risk Stratification Use of Thrombolytic Therapy in High-Risk Pulmonary Embolism Use of Thrombolytic Therapy in Intermediate-Risk Pulmonary Embolism Use of Thrombolytic Therapy in Low-Risk Pulmonary Embolism Other Considerations Low-Dose Thrombolysis Catheter-Directed Thrombolysis Cardiopulmonary Arrest Impact of Thrombolysis on Long-Term Outcomes Mortality Hemodynamics and RV Function Venous Thromboembolism Recurrence Bleeding Summary References Endovascular Techniques in the Treatment of Acute PE Introduction to Catheter-Directed Therapy Role and Rationale for Catheter-Directed Therapy Evidence for Catheter-Directed Therapy Contraindications to Catheter-Directed Therapy Preparation for Catheter-Directed Therapy Procedure Walkthrough Periprocedural IVC Filter Placement Follow-Up Care References Role of Surgical Embolectomy and ECMO in PE The History of Surgical Therapy for Acute Pulmonary Emboli SPE and Outcomes in the Modern Era Indications for Surgical Pulmonary Embolectomy Surgical Procedure SPE as First-Line Therapy VA-ECMO in PE Conclusion References Inferior Vena Cava Filters in Venous Thromboembolism Introduction and Background Types of IVC Filters Indications for Filter Placement Evidence-Based Literature Review Complications of IVC Filters Future Directions References Multidisciplinary PE Response Team Development and Implementation Background PERT Review of Published PERT Data PERT Consortium References Post-PE Management Introduction The Outpatient Clinic Setting – Follow-Up After Acute PE Symptoms History: The Initial Event Risk Factors for VTE Assessment of Bleeding Risk Medication Review Physical Examination and Laboratory Testing Physical Examination Laboratory Testing Anticoagulation Post-Pulmonary Embolism Drug Interactions Renal and Hepatic Insufficiency Obesity and Anticoagulants Anticoagulant Absorption and Bariatric Surgery Cancer and Anticoagulants Duration of Anticoagulation: Persisting Risk of VTE and Thrombophilia Testing Duration of Anticoagulation Thrombophilia Testing Screening for Malignancy Other Aspects of Post-Pulmonary Embolism Management Oxygen Requirement Post-PE Inferior Vena Caval (IVC) Filters Post-Thrombotic Syndrome (PTS) Post-PE Rehabilitation Management of Recurrent VTE Post-PE Dyspnea Post-PE Diagnostic Imaging Long-Term Survival and VTE Recurrence: What to Tell the Patient Conclusions References Epidemiology and Diagnosis of Chronic Thromboembolic Pulmonary Hypertension Background Epidemiology of CTEPH Risk Factors for CTEPH Screening for CTEPH Diagnosis of CTEPH Symptoms and Exam EKG Chest X-Ray Pulmonary Functions Tests Echocardiography Ventilation/Perfusion Scintigraphy (VQ) Single Photon Emission Computed Tomography (SPECT-VQ) Computed Tomography Pulmonary Angiography (CTPA) Dual-Energy CT Digital Subtraction Angiography Magnetic Resonance Angiography (MRA) Right Heart Catheterization Cardiopulmonary Exercise Testing Mimickers of CTEPH Conclusions References Medical, Endovascular, and Surgical Treatment of CTEPH Introduction Surgical Treatment Balloon Pulmonary Angioplasty Medical Therapy Conclusion References Index