Embolismul pulmonar acut Dan Hutanu, rezident Geriatrie-Gerontologie

Definitie :Embolismul pulmonar este rezultatul impactului realizat de un tromb venos dislocat sau de un alt material propagat in circulatia arteriala pulmonara .

Epidemiologie Embolismul pulmonar si tromboza venoasa profunda sunt doua forme clinice ale tromboembolismului venos si au aceeasi factori predispozanti .De cele mai multe ori embolismul pulmonar este consecinta trombozei venoase profunde .Tromboza venoasa profunda a membrelor inferioare poate fi intalnita la aproximati 70% din pacientii cu embolism pulmonar .Studiile autopsice releva embolia pulmonara drept cauza a 15-20% din totalul deceselor.

Factori predispozanti Desi embolismul pulmonar poate apare la pacienti fara factori predispozanti identificabili in aproximativ 20% din cazuri , unul sau mai multi dintre acesti factori sunt frecvent identificabili. Tromboebolismul venos este acum privit ca rezultat al interactiunii factorilor de risc legati de pacient si cei legati de imprejurari.

Factori predispozanti cu putere statistica inalta

Factori predispozanti cu putere statistica moderata

Factori predispozanti cu putere statistica minora

Evolutie naturalaEmbolismul pulmonar se prezinta cu soc sau hipotensiune arteriala in 10% din cazuri si pana la 50% fara soc dar cu disfunctie vantriculara dreapta cu prognostic prost.Embolismul pulmonar este fatal la 10% din pacienti in prima ora de la debutul simptomelor. Rata deceselor este> 90% la pacientii netratati .Fara anticoagulare aproximativ 50%din pacientii cu tromboza venoasa profunda au o recurenta in 3 luni.

Fiziopatologie

Evaluarea clinica initiala I

Evaluarea clinica initiala II

Scorul Geneva revizuit

Markeri principali utili pentru stratificarea riscului

Stratificarea riscului in functie de rata estimata a mortalitatii precoce asociata embolismului pulmonar

RV-right ventriclePE-pulmonary embolism(+)a-whitout shock /hypotension

DiagnosticSimptomatologia clinicaAnaliza gazelor sanguineRadiografia toracicaElectrocardiogramaD-dimerul plasmaticUltrasonografia venoasa a membrelor inferioareEcocardiografiaScintigrafia pulmonaraAngiografia pulmonaraAngiografia CT

Algoritm de diagnostic I

Algoritm de diagnostic II

Excluderea emboliei pulmonare la pacientii fara risc inalt

Confirmarea emboliei pulmonare la pacientii fara risc inalt

Recomandari tratament EP cu risc inaltAnticoagularea cu heparine nefractionate trebuie initiata fara intarziere (clasa I, nivel A)Corectarea hipotensiunii arteriale (clasa I, nivel C)Medicatie vasopresoare (clasa I, nivel C)Dopamina si dobutamina pot fi folosite la pacientii cu embolism pulmonar cu debit cardiac scazut si tensiune arteriala normala (clasa IIa, nivel B)Nu este recomandata incarcarea agresiva cu fluide (clasa III, nivel B)Administrare oxigen in hipoxemie (clasa I ,nivel C)Tromboliza (clasa I, nivel C)Embolectomia chirurgicala (clasa I, nivel C)Embolectomie pe cateter (clasa IIb, nivel C)

Recomandari tratament EP fara risc inaltAnticoagularea trebuie initiata fara intarziere la pacientii cu probabilitate clinica mare sau intermediara (clasaI, nivelC)Sunt recomandate heparinele cu greutate moleculara mica sau fondaparina subcutanat (clasa I, nivel A )La pacientii cu risc crescut de sangerare sau cu disfunctie renala severa este indicat ca tratament initial heparina nefractionate i-v (clasa I ,nivelC)Tratamentul initial cu heparine trebuie continuat minim 5 zile (clasa I, nivelA ) si apoi poate fi inlocuit cu antagonisti ai vitaminei k (clasa I, nivel C)Trombolizei de rutina poate fi luata in considerare la pacienti selectionati cu EP cu risc intermediar (clasa IIb, nivel B)Tromboliza nu trebuie utilizata la pacientii cu risc scazut de EP (clasa III, nivel B)

Anticoagularea pe termen lungEmbolism pulmonar secundar - 3 luni antagonist vitamina k (clasa I, nivel A)Embolism pulmonar idiopatic - >3 luni antagonist vitamina k (clasa I ,nivel A )Pentru pacientii cu un al doilea episod de EP neprovocat este recomandat tratamentul anticoagulant pe termen lung( clasa I, nivel A )Embolism pulmonar +cancer - heparina nefractionata 6 luni ( clasa IIa, nivel B ) apoi indefinit heparina nefractionata sau antagonist de vitamina k (clasa I, nivel C)

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