embolia pulmonar
TRANSCRIPT
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
Meacutedico HUGG-UNIRIO
Embolia Pulmonar
Aspectos Epidemioloacutegicos
Incidecircncia na populaccedilatildeo geral estimada em 100 a 200 por 100000 pacientes 250000 internaccedilotildeesano nos EUA
Uma das maiores causas de morte em pacientes internados
Mortalidade 4 vezes maior quando o tratamento adequado natildeo eacute instituiacutedo
2deg causa de morte suacutebita nos EUA
Risco de recorrecircncia eacute maior nas primeiras 2 semanas
Embolia Pulmonar
Fatores PredisponentesTVP
previaIdade gt 65
anos
Neoplasia
Pos opCirurgia grande porte
Lesatildeo medular
Imobilizaccedilatildeo prolongada
Probabilidade Preacute-teste
Thromb Haemost 2000 83(3) 416-420
Ann Inter Med 2006 144(3) 165-171
Definindo risco
Alto Risco ( + 15 oacutebito precoce)Hipotensatildeo Choque
Moderado Risco (3 a 15 oacutebito)Dilataccedilatildeo hipocinesia ou sobrecarga de VD no EcoDilataccedilatildeo de VD na TCElevaccedilatildeo de BNPTroponina +
PESI - Escore Prognoacutestico
Eur Heart J 2014 35 3033-3080
Classificaccedilatildeo de Risco de Mortalidade
Eur Heart J 2014 35 3033-3080
Kaumlberich A Management of Acute Pulmonary Embolism Recent Evidence New Guidelines Rambam Maimonides Med J 20145 (4) e0040
Definiccedilatildeo Prognoacutestica Estrateacutegia Terapecircutica
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia Pulmonar
Diagnoacutestico
Embolia Pulmonar
Como Tratar
Diagnoacutestico Clinico de TEP
Estabilidade Hemodinacircmica sem
disfunccedilatildeo de VD
Anticoagulaccedilatildeo
Estabilidade hemodinacircmica com Disfunccedilatildeo de VD
(Eco com disf VD BNP gt 100 troponina + Relaccedilatildeo VDVE gt 11)
TromboliseIntraarterial
Instabilidade hemodinacircmica
TromboliseSistecircmica
Embolia Pulmonar
Como Tratar
Suporte Hemodinacircmico e
respiratoacuterio
Anticoagulaccedilatildeo com HNF ou HBPM (5 dias
iniciais)
Anticoagulaccedilao oral (coumarinico ou
novos anticoagulantes)
Anticoagulantes Orais Esquema Terapecircutico
Apixaban (Eliquis) 10 mg 1212 horas por 7 dias e apoacutes 5 mg 1212 horas
Dabigatrana (Pradaxa) 150 mg 1212 horas
Endoxabana 60 mg ao dia
Rivaroxabana (Xarelto) 15 mg 1212 horas por 3 semanas e apoacutes 20 mg ao dia
Paciente Estaacutevel Hemodinamicamente
Acesso perifeacutericoMonitorizaccedilatildeo de sinais vitaisSuplementaccedilatildeo de oxigecircnio
Risco de sangramentoBeneficio da anticoagulaccedilatildeo
HBPM semelhante a HNF com lt risco palquetopeniaIdosos obesos baixo peso Disfunccedilatildeo renal (Cllt30)
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Embolia Pulmonar
Aspectos Epidemioloacutegicos
Incidecircncia na populaccedilatildeo geral estimada em 100 a 200 por 100000 pacientes 250000 internaccedilotildeesano nos EUA
Uma das maiores causas de morte em pacientes internados
Mortalidade 4 vezes maior quando o tratamento adequado natildeo eacute instituiacutedo
2deg causa de morte suacutebita nos EUA
Risco de recorrecircncia eacute maior nas primeiras 2 semanas
Embolia Pulmonar
Fatores PredisponentesTVP
previaIdade gt 65
anos
Neoplasia
Pos opCirurgia grande porte
Lesatildeo medular
Imobilizaccedilatildeo prolongada
Probabilidade Preacute-teste
Thromb Haemost 2000 83(3) 416-420
Ann Inter Med 2006 144(3) 165-171
Definindo risco
Alto Risco ( + 15 oacutebito precoce)Hipotensatildeo Choque
Moderado Risco (3 a 15 oacutebito)Dilataccedilatildeo hipocinesia ou sobrecarga de VD no EcoDilataccedilatildeo de VD na TCElevaccedilatildeo de BNPTroponina +
PESI - Escore Prognoacutestico
Eur Heart J 2014 35 3033-3080
Classificaccedilatildeo de Risco de Mortalidade
Eur Heart J 2014 35 3033-3080
Kaumlberich A Management of Acute Pulmonary Embolism Recent Evidence New Guidelines Rambam Maimonides Med J 20145 (4) e0040
Definiccedilatildeo Prognoacutestica Estrateacutegia Terapecircutica
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia Pulmonar
Diagnoacutestico
Embolia Pulmonar
Como Tratar
Diagnoacutestico Clinico de TEP
Estabilidade Hemodinacircmica sem
disfunccedilatildeo de VD
Anticoagulaccedilatildeo
Estabilidade hemodinacircmica com Disfunccedilatildeo de VD
(Eco com disf VD BNP gt 100 troponina + Relaccedilatildeo VDVE gt 11)
TromboliseIntraarterial
Instabilidade hemodinacircmica
TromboliseSistecircmica
Embolia Pulmonar
Como Tratar
Suporte Hemodinacircmico e
respiratoacuterio
Anticoagulaccedilatildeo com HNF ou HBPM (5 dias
iniciais)
Anticoagulaccedilao oral (coumarinico ou
novos anticoagulantes)
Anticoagulantes Orais Esquema Terapecircutico
Apixaban (Eliquis) 10 mg 1212 horas por 7 dias e apoacutes 5 mg 1212 horas
Dabigatrana (Pradaxa) 150 mg 1212 horas
Endoxabana 60 mg ao dia
Rivaroxabana (Xarelto) 15 mg 1212 horas por 3 semanas e apoacutes 20 mg ao dia
Paciente Estaacutevel Hemodinamicamente
Acesso perifeacutericoMonitorizaccedilatildeo de sinais vitaisSuplementaccedilatildeo de oxigecircnio
Risco de sangramentoBeneficio da anticoagulaccedilatildeo
HBPM semelhante a HNF com lt risco palquetopeniaIdosos obesos baixo peso Disfunccedilatildeo renal (Cllt30)
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Embolia Pulmonar
Fatores PredisponentesTVP
previaIdade gt 65
anos
Neoplasia
Pos opCirurgia grande porte
Lesatildeo medular
Imobilizaccedilatildeo prolongada
Probabilidade Preacute-teste
Thromb Haemost 2000 83(3) 416-420
Ann Inter Med 2006 144(3) 165-171
Definindo risco
Alto Risco ( + 15 oacutebito precoce)Hipotensatildeo Choque
Moderado Risco (3 a 15 oacutebito)Dilataccedilatildeo hipocinesia ou sobrecarga de VD no EcoDilataccedilatildeo de VD na TCElevaccedilatildeo de BNPTroponina +
PESI - Escore Prognoacutestico
Eur Heart J 2014 35 3033-3080
Classificaccedilatildeo de Risco de Mortalidade
Eur Heart J 2014 35 3033-3080
Kaumlberich A Management of Acute Pulmonary Embolism Recent Evidence New Guidelines Rambam Maimonides Med J 20145 (4) e0040
Definiccedilatildeo Prognoacutestica Estrateacutegia Terapecircutica
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia Pulmonar
Diagnoacutestico
Embolia Pulmonar
Como Tratar
Diagnoacutestico Clinico de TEP
Estabilidade Hemodinacircmica sem
disfunccedilatildeo de VD
Anticoagulaccedilatildeo
Estabilidade hemodinacircmica com Disfunccedilatildeo de VD
(Eco com disf VD BNP gt 100 troponina + Relaccedilatildeo VDVE gt 11)
TromboliseIntraarterial
Instabilidade hemodinacircmica
TromboliseSistecircmica
Embolia Pulmonar
Como Tratar
Suporte Hemodinacircmico e
respiratoacuterio
Anticoagulaccedilatildeo com HNF ou HBPM (5 dias
iniciais)
Anticoagulaccedilao oral (coumarinico ou
novos anticoagulantes)
Anticoagulantes Orais Esquema Terapecircutico
Apixaban (Eliquis) 10 mg 1212 horas por 7 dias e apoacutes 5 mg 1212 horas
Dabigatrana (Pradaxa) 150 mg 1212 horas
Endoxabana 60 mg ao dia
Rivaroxabana (Xarelto) 15 mg 1212 horas por 3 semanas e apoacutes 20 mg ao dia
Paciente Estaacutevel Hemodinamicamente
Acesso perifeacutericoMonitorizaccedilatildeo de sinais vitaisSuplementaccedilatildeo de oxigecircnio
Risco de sangramentoBeneficio da anticoagulaccedilatildeo
HBPM semelhante a HNF com lt risco palquetopeniaIdosos obesos baixo peso Disfunccedilatildeo renal (Cllt30)
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Probabilidade Preacute-teste
Thromb Haemost 2000 83(3) 416-420
Ann Inter Med 2006 144(3) 165-171
Definindo risco
Alto Risco ( + 15 oacutebito precoce)Hipotensatildeo Choque
Moderado Risco (3 a 15 oacutebito)Dilataccedilatildeo hipocinesia ou sobrecarga de VD no EcoDilataccedilatildeo de VD na TCElevaccedilatildeo de BNPTroponina +
PESI - Escore Prognoacutestico
Eur Heart J 2014 35 3033-3080
Classificaccedilatildeo de Risco de Mortalidade
Eur Heart J 2014 35 3033-3080
Kaumlberich A Management of Acute Pulmonary Embolism Recent Evidence New Guidelines Rambam Maimonides Med J 20145 (4) e0040
Definiccedilatildeo Prognoacutestica Estrateacutegia Terapecircutica
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia Pulmonar
Diagnoacutestico
Embolia Pulmonar
Como Tratar
Diagnoacutestico Clinico de TEP
Estabilidade Hemodinacircmica sem
disfunccedilatildeo de VD
Anticoagulaccedilatildeo
Estabilidade hemodinacircmica com Disfunccedilatildeo de VD
(Eco com disf VD BNP gt 100 troponina + Relaccedilatildeo VDVE gt 11)
TromboliseIntraarterial
Instabilidade hemodinacircmica
TromboliseSistecircmica
Embolia Pulmonar
Como Tratar
Suporte Hemodinacircmico e
respiratoacuterio
Anticoagulaccedilatildeo com HNF ou HBPM (5 dias
iniciais)
Anticoagulaccedilao oral (coumarinico ou
novos anticoagulantes)
Anticoagulantes Orais Esquema Terapecircutico
Apixaban (Eliquis) 10 mg 1212 horas por 7 dias e apoacutes 5 mg 1212 horas
Dabigatrana (Pradaxa) 150 mg 1212 horas
Endoxabana 60 mg ao dia
Rivaroxabana (Xarelto) 15 mg 1212 horas por 3 semanas e apoacutes 20 mg ao dia
Paciente Estaacutevel Hemodinamicamente
Acesso perifeacutericoMonitorizaccedilatildeo de sinais vitaisSuplementaccedilatildeo de oxigecircnio
Risco de sangramentoBeneficio da anticoagulaccedilatildeo
HBPM semelhante a HNF com lt risco palquetopeniaIdosos obesos baixo peso Disfunccedilatildeo renal (Cllt30)
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Definindo risco
Alto Risco ( + 15 oacutebito precoce)Hipotensatildeo Choque
Moderado Risco (3 a 15 oacutebito)Dilataccedilatildeo hipocinesia ou sobrecarga de VD no EcoDilataccedilatildeo de VD na TCElevaccedilatildeo de BNPTroponina +
PESI - Escore Prognoacutestico
Eur Heart J 2014 35 3033-3080
Classificaccedilatildeo de Risco de Mortalidade
Eur Heart J 2014 35 3033-3080
Kaumlberich A Management of Acute Pulmonary Embolism Recent Evidence New Guidelines Rambam Maimonides Med J 20145 (4) e0040
Definiccedilatildeo Prognoacutestica Estrateacutegia Terapecircutica
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia Pulmonar
Diagnoacutestico
Embolia Pulmonar
Como Tratar
Diagnoacutestico Clinico de TEP
Estabilidade Hemodinacircmica sem
disfunccedilatildeo de VD
Anticoagulaccedilatildeo
Estabilidade hemodinacircmica com Disfunccedilatildeo de VD
(Eco com disf VD BNP gt 100 troponina + Relaccedilatildeo VDVE gt 11)
TromboliseIntraarterial
Instabilidade hemodinacircmica
TromboliseSistecircmica
Embolia Pulmonar
Como Tratar
Suporte Hemodinacircmico e
respiratoacuterio
Anticoagulaccedilatildeo com HNF ou HBPM (5 dias
iniciais)
Anticoagulaccedilao oral (coumarinico ou
novos anticoagulantes)
Anticoagulantes Orais Esquema Terapecircutico
Apixaban (Eliquis) 10 mg 1212 horas por 7 dias e apoacutes 5 mg 1212 horas
Dabigatrana (Pradaxa) 150 mg 1212 horas
Endoxabana 60 mg ao dia
Rivaroxabana (Xarelto) 15 mg 1212 horas por 3 semanas e apoacutes 20 mg ao dia
Paciente Estaacutevel Hemodinamicamente
Acesso perifeacutericoMonitorizaccedilatildeo de sinais vitaisSuplementaccedilatildeo de oxigecircnio
Risco de sangramentoBeneficio da anticoagulaccedilatildeo
HBPM semelhante a HNF com lt risco palquetopeniaIdosos obesos baixo peso Disfunccedilatildeo renal (Cllt30)
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
PESI - Escore Prognoacutestico
Eur Heart J 2014 35 3033-3080
Classificaccedilatildeo de Risco de Mortalidade
Eur Heart J 2014 35 3033-3080
Kaumlberich A Management of Acute Pulmonary Embolism Recent Evidence New Guidelines Rambam Maimonides Med J 20145 (4) e0040
Definiccedilatildeo Prognoacutestica Estrateacutegia Terapecircutica
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia Pulmonar
Diagnoacutestico
Embolia Pulmonar
Como Tratar
Diagnoacutestico Clinico de TEP
Estabilidade Hemodinacircmica sem
disfunccedilatildeo de VD
Anticoagulaccedilatildeo
Estabilidade hemodinacircmica com Disfunccedilatildeo de VD
(Eco com disf VD BNP gt 100 troponina + Relaccedilatildeo VDVE gt 11)
TromboliseIntraarterial
Instabilidade hemodinacircmica
TromboliseSistecircmica
Embolia Pulmonar
Como Tratar
Suporte Hemodinacircmico e
respiratoacuterio
Anticoagulaccedilatildeo com HNF ou HBPM (5 dias
iniciais)
Anticoagulaccedilao oral (coumarinico ou
novos anticoagulantes)
Anticoagulantes Orais Esquema Terapecircutico
Apixaban (Eliquis) 10 mg 1212 horas por 7 dias e apoacutes 5 mg 1212 horas
Dabigatrana (Pradaxa) 150 mg 1212 horas
Endoxabana 60 mg ao dia
Rivaroxabana (Xarelto) 15 mg 1212 horas por 3 semanas e apoacutes 20 mg ao dia
Paciente Estaacutevel Hemodinamicamente
Acesso perifeacutericoMonitorizaccedilatildeo de sinais vitaisSuplementaccedilatildeo de oxigecircnio
Risco de sangramentoBeneficio da anticoagulaccedilatildeo
HBPM semelhante a HNF com lt risco palquetopeniaIdosos obesos baixo peso Disfunccedilatildeo renal (Cllt30)
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Classificaccedilatildeo de Risco de Mortalidade
Eur Heart J 2014 35 3033-3080
Kaumlberich A Management of Acute Pulmonary Embolism Recent Evidence New Guidelines Rambam Maimonides Med J 20145 (4) e0040
Definiccedilatildeo Prognoacutestica Estrateacutegia Terapecircutica
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia Pulmonar
Diagnoacutestico
Embolia Pulmonar
Como Tratar
Diagnoacutestico Clinico de TEP
Estabilidade Hemodinacircmica sem
disfunccedilatildeo de VD
Anticoagulaccedilatildeo
Estabilidade hemodinacircmica com Disfunccedilatildeo de VD
(Eco com disf VD BNP gt 100 troponina + Relaccedilatildeo VDVE gt 11)
TromboliseIntraarterial
Instabilidade hemodinacircmica
TromboliseSistecircmica
Embolia Pulmonar
Como Tratar
Suporte Hemodinacircmico e
respiratoacuterio
Anticoagulaccedilatildeo com HNF ou HBPM (5 dias
iniciais)
Anticoagulaccedilao oral (coumarinico ou
novos anticoagulantes)
Anticoagulantes Orais Esquema Terapecircutico
Apixaban (Eliquis) 10 mg 1212 horas por 7 dias e apoacutes 5 mg 1212 horas
Dabigatrana (Pradaxa) 150 mg 1212 horas
Endoxabana 60 mg ao dia
Rivaroxabana (Xarelto) 15 mg 1212 horas por 3 semanas e apoacutes 20 mg ao dia
Paciente Estaacutevel Hemodinamicamente
Acesso perifeacutericoMonitorizaccedilatildeo de sinais vitaisSuplementaccedilatildeo de oxigecircnio
Risco de sangramentoBeneficio da anticoagulaccedilatildeo
HBPM semelhante a HNF com lt risco palquetopeniaIdosos obesos baixo peso Disfunccedilatildeo renal (Cllt30)
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Kaumlberich A Management of Acute Pulmonary Embolism Recent Evidence New Guidelines Rambam Maimonides Med J 20145 (4) e0040
Definiccedilatildeo Prognoacutestica Estrateacutegia Terapecircutica
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia Pulmonar
Diagnoacutestico
Embolia Pulmonar
Como Tratar
Diagnoacutestico Clinico de TEP
Estabilidade Hemodinacircmica sem
disfunccedilatildeo de VD
Anticoagulaccedilatildeo
Estabilidade hemodinacircmica com Disfunccedilatildeo de VD
(Eco com disf VD BNP gt 100 troponina + Relaccedilatildeo VDVE gt 11)
TromboliseIntraarterial
Instabilidade hemodinacircmica
TromboliseSistecircmica
Embolia Pulmonar
Como Tratar
Suporte Hemodinacircmico e
respiratoacuterio
Anticoagulaccedilatildeo com HNF ou HBPM (5 dias
iniciais)
Anticoagulaccedilao oral (coumarinico ou
novos anticoagulantes)
Anticoagulantes Orais Esquema Terapecircutico
Apixaban (Eliquis) 10 mg 1212 horas por 7 dias e apoacutes 5 mg 1212 horas
Dabigatrana (Pradaxa) 150 mg 1212 horas
Endoxabana 60 mg ao dia
Rivaroxabana (Xarelto) 15 mg 1212 horas por 3 semanas e apoacutes 20 mg ao dia
Paciente Estaacutevel Hemodinamicamente
Acesso perifeacutericoMonitorizaccedilatildeo de sinais vitaisSuplementaccedilatildeo de oxigecircnio
Risco de sangramentoBeneficio da anticoagulaccedilatildeo
HBPM semelhante a HNF com lt risco palquetopeniaIdosos obesos baixo peso Disfunccedilatildeo renal (Cllt30)
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia Pulmonar
Diagnoacutestico
Embolia Pulmonar
Como Tratar
Diagnoacutestico Clinico de TEP
Estabilidade Hemodinacircmica sem
disfunccedilatildeo de VD
Anticoagulaccedilatildeo
Estabilidade hemodinacircmica com Disfunccedilatildeo de VD
(Eco com disf VD BNP gt 100 troponina + Relaccedilatildeo VDVE gt 11)
TromboliseIntraarterial
Instabilidade hemodinacircmica
TromboliseSistecircmica
Embolia Pulmonar
Como Tratar
Suporte Hemodinacircmico e
respiratoacuterio
Anticoagulaccedilatildeo com HNF ou HBPM (5 dias
iniciais)
Anticoagulaccedilao oral (coumarinico ou
novos anticoagulantes)
Anticoagulantes Orais Esquema Terapecircutico
Apixaban (Eliquis) 10 mg 1212 horas por 7 dias e apoacutes 5 mg 1212 horas
Dabigatrana (Pradaxa) 150 mg 1212 horas
Endoxabana 60 mg ao dia
Rivaroxabana (Xarelto) 15 mg 1212 horas por 3 semanas e apoacutes 20 mg ao dia
Paciente Estaacutevel Hemodinamicamente
Acesso perifeacutericoMonitorizaccedilatildeo de sinais vitaisSuplementaccedilatildeo de oxigecircnio
Risco de sangramentoBeneficio da anticoagulaccedilatildeo
HBPM semelhante a HNF com lt risco palquetopeniaIdosos obesos baixo peso Disfunccedilatildeo renal (Cllt30)
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Embolia Pulmonar
Como Tratar
Diagnoacutestico Clinico de TEP
Estabilidade Hemodinacircmica sem
disfunccedilatildeo de VD
Anticoagulaccedilatildeo
Estabilidade hemodinacircmica com Disfunccedilatildeo de VD
(Eco com disf VD BNP gt 100 troponina + Relaccedilatildeo VDVE gt 11)
TromboliseIntraarterial
Instabilidade hemodinacircmica
TromboliseSistecircmica
Embolia Pulmonar
Como Tratar
Suporte Hemodinacircmico e
respiratoacuterio
Anticoagulaccedilatildeo com HNF ou HBPM (5 dias
iniciais)
Anticoagulaccedilao oral (coumarinico ou
novos anticoagulantes)
Anticoagulantes Orais Esquema Terapecircutico
Apixaban (Eliquis) 10 mg 1212 horas por 7 dias e apoacutes 5 mg 1212 horas
Dabigatrana (Pradaxa) 150 mg 1212 horas
Endoxabana 60 mg ao dia
Rivaroxabana (Xarelto) 15 mg 1212 horas por 3 semanas e apoacutes 20 mg ao dia
Paciente Estaacutevel Hemodinamicamente
Acesso perifeacutericoMonitorizaccedilatildeo de sinais vitaisSuplementaccedilatildeo de oxigecircnio
Risco de sangramentoBeneficio da anticoagulaccedilatildeo
HBPM semelhante a HNF com lt risco palquetopeniaIdosos obesos baixo peso Disfunccedilatildeo renal (Cllt30)
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Diagnoacutestico Clinico de TEP
Estabilidade Hemodinacircmica sem
disfunccedilatildeo de VD
Anticoagulaccedilatildeo
Estabilidade hemodinacircmica com Disfunccedilatildeo de VD
(Eco com disf VD BNP gt 100 troponina + Relaccedilatildeo VDVE gt 11)
TromboliseIntraarterial
Instabilidade hemodinacircmica
TromboliseSistecircmica
Embolia Pulmonar
Como Tratar
Suporte Hemodinacircmico e
respiratoacuterio
Anticoagulaccedilatildeo com HNF ou HBPM (5 dias
iniciais)
Anticoagulaccedilao oral (coumarinico ou
novos anticoagulantes)
Anticoagulantes Orais Esquema Terapecircutico
Apixaban (Eliquis) 10 mg 1212 horas por 7 dias e apoacutes 5 mg 1212 horas
Dabigatrana (Pradaxa) 150 mg 1212 horas
Endoxabana 60 mg ao dia
Rivaroxabana (Xarelto) 15 mg 1212 horas por 3 semanas e apoacutes 20 mg ao dia
Paciente Estaacutevel Hemodinamicamente
Acesso perifeacutericoMonitorizaccedilatildeo de sinais vitaisSuplementaccedilatildeo de oxigecircnio
Risco de sangramentoBeneficio da anticoagulaccedilatildeo
HBPM semelhante a HNF com lt risco palquetopeniaIdosos obesos baixo peso Disfunccedilatildeo renal (Cllt30)
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Suporte Hemodinacircmico e
respiratoacuterio
Anticoagulaccedilatildeo com HNF ou HBPM (5 dias
iniciais)
Anticoagulaccedilao oral (coumarinico ou
novos anticoagulantes)
Anticoagulantes Orais Esquema Terapecircutico
Apixaban (Eliquis) 10 mg 1212 horas por 7 dias e apoacutes 5 mg 1212 horas
Dabigatrana (Pradaxa) 150 mg 1212 horas
Endoxabana 60 mg ao dia
Rivaroxabana (Xarelto) 15 mg 1212 horas por 3 semanas e apoacutes 20 mg ao dia
Paciente Estaacutevel Hemodinamicamente
Acesso perifeacutericoMonitorizaccedilatildeo de sinais vitaisSuplementaccedilatildeo de oxigecircnio
Risco de sangramentoBeneficio da anticoagulaccedilatildeo
HBPM semelhante a HNF com lt risco palquetopeniaIdosos obesos baixo peso Disfunccedilatildeo renal (Cllt30)
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Trombolizar
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Impacto do Tratamento Tromboliacutetico na TEP
= Benefiacutecio Liacutequido
(ldquoNet Clinical Benefitrdquo)
Risco
Hemorraacutegico
1) Mortalidade
2) Perda funcional grave
Eficaacutecia de Reperfusatildeo
1) Reduccedilatildeo de Mortalidade
2) Melhora funcional precoce e em longo prazo
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Trombolitico
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Limitaccedilotildees Gerais dos Ensaios Cliacutenicos
bull Utilizaccedilatildeo de desfecho composto
bull Sangramento como desfecho de seguranccedila e natildeo eficaacutecia
bull Subrepresentaccedilatildeo de Idosos mulheres baixo peso e disfunccedilatildeo renal
bull Variedade nos criteacuterios de sangramento maior
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Thrombolytic Therapy in Unstable Patients with Acute Pulmonary Embolism Saves Lives but Underused
bull Registro Norte Americano 72230 casos TEP ldquoinstaacutevelrdquo
bull 1999-2008
bull Avaliaccedilatildeo de letalidade
bull 30 receberam tromboacutelise
bull Letalidade grupo TBL
- Geral=15 Atribuiacuteda agrave TEP=84
bull Letalidade grupo natildeo TBL
- Geral=47 (Plt0001) Atribuiacuteda agrave TEP=42 (Plt0001)
Am J Med 2012 May125(5)465-70
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Tromboacutelise no TEP Submaciccedilo
bull 256 Pacientes sem hipotensatildeo com disfunccedilatildeo de VD ou HAP (ECO CAT direito)
bull Heparina + Placebo X heparina + Alteplase
bull Desfecho Morte ou Deteriorizaccedilatildeo Cliacutenica
N Engl J Med 20023471143-50
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
bull 1005 pacientes Tenecteplase X Heparina
bull Normotensos com Disfunccedilatildeo de VD (ECO TC) e Elevaccedilatildeo de Troponina
bull Desfecho= Morte ou Piora hemodinacircmica em 7 dias
bull Impacto na piora hemodinacircmica
bull Aumento de Sangramento Extra-Craniano e AVE total
N Engl J Med 37015 april 10 2014
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
bull 16 estudos=2115 pc
bull 8 estudos=1775 pacientes com TEP submaciccedilo
bull Reduccedilatildeo de Mortalidade por todas as causas
bull Aumento de eventos de sangramento
Chatterjee S JAMA 2014 Jun 18311(23)2414-21
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
bull Para 100 pac Trombolizados
bull Evita 2 mortes 2 Recorrecircncias de TEP
bull Provoca 1 AVEH e 6 Sang Maiores
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
ldquoTo Bleed or Not to Bleedrdquo ldquoThat is the Questionrdquo
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
ldquoNenhum estudo demonstra diminuiccedilatildeo da mortalidade para tromboacutelise em pacientes com TEP submaciccedilo apenas melhora da disfunccedilatildeo de VD mas sem benefiacutecio hemodinacircmico a longo prazordquo
CHEST 143 February 2013 - PointConterpoint Editorials
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Tromboacutelise em todos os Pacientes
bull Natildeo
bull Para pc de Risco elevado e Risco Intermediaacuterio-Alto
bull Classificar Risco (PESI ou sPESI + Dados de Imagem e LAB)
bull Considerar Risco hemorraacutegico e CI para tromboacutelise
bull Considerar Meacutetodos Alternativos de Reperfusatildeo
bull Perspectiva futura para reduccedilatildeo de doses
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Evidecircncias Diretrizes
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Novas Perspectivas Tromboacutelise por Cateter
bull 59 pacientes - TEP Risco intermediaacuterio
bull CBT X Heparina
bull Impacto na Melhora funcional do VD
bull Natildeo aumentou sangramento
Circulation 2014129479-486)
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
AbstractBACKGROUND Systemic thrombolysis for acute pulmonary embolism (PE) carries up to a 20 risk of major bleeding including a 2 to 5 risk of hemorrhagic stroke We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment of acute PEMETHODS One hundred one consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry Massive PE (n = 28) and submassive PE (n = 73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy andor catheter-directed thrombolysis through low-dose hourly drug infusion with tissue plasminogen activator (tPA) or urokinase Clinical success was defined as meeting all the following criteria stabilization of hemodynamics improvement in pulmonary hypertension right-sided heart strain or both and survival to hospital discharge Primary safety outcomes were major procedure-related complications and major bleeding eventsRESULTS Fifty-three men and 48 women (average age 60 years [range 22-86 years] mean BMI 3103 plusmn 720 kgm2) were included in the study The average thrombolytic doses were 280 plusmn 11 mg tPA (n = 76) and 2697101 plusmn 936287 International Units for urokinase (n = 23) Clinical success was achieved in 24 of 28 patients with massive PE (857 95 CI 673-960) and 71 of 73 patients with submassive PE (973 95 CI 905-997) The mean pulmonary artery pressure improved from 5117 plusmn 1406 to 3723 plusmn 1581 mm Hg (n = 92) (P lt 0001) Among patients monitored with follow-up echocardiography 57 of 64 (891 95 CI 788-955 P lt 0001) showed improvement in right-sided heart strain There were no major procedure-related complications major hemorrhages or hemorrhagic strokesCONCLUSIONS
CDT improves clinical outcomes in patients with acute PE while minimizing the risk of major bleeding At experienced centers CDT is a safe and effective treatment of both acute massive and submassive PE
Pulmonary Embolism Response to Fragmentation Embolectomy and Catheter Thrombolysis (PERFECT) Initial Results from a Prospective Multicenter RegistryKuo W T Banerjee A Kim P S DeMarco F J Levy J R Facchini F R Unver K Bertini M J Sista A K Hall M J Rosenberg J K DeGregorio M A
Chest 2015 April 9 [Epub ahead of print]
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial
ldquoAmong hospitalized patients with severe acute pulmonary embolism the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months These findings do not support the use of this type of filter in patients who can be treated with anticoagulationrdquo
Patrick Mismetti Silvy Laporte Olivier Pellerin et al
JAMA 2015313(16)1627-1635
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Instabilidade Hemodinacircmica(PA Sistoacutelica lt 90mmHg por 15min ouqueda de 40mmHg durante a avaliaccedilatildeoinicial ou necessidade de drogas vaso-ativas ou suporte ventilatoacuterio ou PCR
EstabilidadeHemodinacircmica Estabilidade Hemodinacircmica +
Disfunccedilatildeo de VD (Eco +Relaccedilatildeo VDVE gt 11 na AngioTC BNP gt 100 ou Troponina +
Tromboacutelise
Anticoagulaccedilatildeo
Tromboacutelise Intra-arterial
Meacutedico responsaacutevel pelo pacienteavalia o risco de se esperar pelaintervenccedilatildeo arterial +- Implante de Filtro de
Veia Cava Temporaacuterio
Suspeita Clinica de TEP
D Dimero Troponina BNP ECG Gasometria
arterial
EcocardiogramaTranstoraacutecico +
Doppler Venoso de MMII
AngioTC Toacuterax + Fase Tardia Venosa
(Abdome pelve e coxa)
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado
Embolia PulmonarDiagnoacutestico e Tratamento
Andreacute Casarsa MarquesMeacutedico Rotina UCI Hospital Barra D`Or
andrecasarsaglobocom
Obrigado