Tep 2009

Tromboembolismo Pulmonar ,[object Object],[object Object],[object Object]

Introducción ,[object Object],[object Object],[object Object],[object Object]

Tromboembolismo Pulmonar ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Agudo Crónico Eur Heart J 2000; 21:1301 Circulation 2005 Jul 12:112 (2): e28-32

[object Object],[object Object],[object Object],42.932.973 mortalidad total 1.3% diagnostico de TEP 33,9% TEP como causa de muerte

[object Object],[object Object],[object Object],79 % TEP presentan TVP 50% TVP proximal desarrolla TEP N Engl J Med 2008;358:1037-52 .

Mortalidad Global 30 % 2-8% con tratamiento ,[object Object],[object Object]

Disfunción Ventrículo Derecho ,[object Object],[object Object],[object Object],[object Object],[object Object],Arch Intern Med 2004 Aug 9-23; 164(15): 1685-9 Eur Heart J. 2008 Jun; 29(12): 1569-77

Péptido Natriurético cerebral (BNP) y péptido natriurético N-terminal (NT-proBNP) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Trombo en ventriculo derecho ,[object Object],[object Object],[object Object],Elevación troponina I y T se asocian a un aumento en la mortalidad a cortoplazo y de eventos adversos Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation. 2007 Jul 24;116(4):427-33 Troponinas séricas

N Engl J Med 2008;358:1037-52.

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

Síntomas Signos Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007 Oct;120(10):871-9. Disnea de esfuerzo o reposo 73% Dolor Pleurítico 44% Dolor pantorrilla o muslo 44% Edema pantorillas o muslo 41% Tos 34% Ortopnea 28% Inicio disnea en seg. 46% Inicio disnea en minutos 26% Taquipnea 54% Taquicardia 24% Crépitos 18% Disminución MP 17% ↑ componente pulmonar 2° ruido 15% Distención yugular 14%

Diagnósticos diferenciales Ansiedad, costocondritis Pneumonia, bronquitis IAM Pericarditis Insuficiencia Cardiaca Congestiva Hipertensión pulmonar idiopática

Score de Wells de Embolia pulmonar ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Thromb Haemost 2000Mar; 83(3):416-20 JAMA 2006; 295:172

Score de Geneva revizado ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],N Engl J Med 2008;358:1037-52. Variable Ptos. >65 años 1 TVP o TEP previo 3 Cirugía o Fractura de EEII 2 Cancer Activo 2 Dolor unilateral de EEII 3 Hemoptisis 2 FC 75-94 x´ 3 FC ≥ 95 x´ 5 Dolor a la palpación o edema unilateral 4

Dimero D ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Chest. 2008 Oct;134(4):789-93 N Engl J Med 2008;358:1037-52. JAMA 2006; 295:172

Desordenes asociados a ↑Dimero-D ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Dimero D ,[object Object],[object Object],Chest. 2008 Oct;134(4):789-93 N Engl J Med 2008;358:1037-52. JAMA 2006; 295:172

BNP ,[object Object],[object Object],[object Object],Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism J Thromb Haemost. 2006 Mar;4(3):552-6 Troponinas ,[object Object],[object Object],[object Object],Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism.Circulation 2000 Jul 11;102(2):211-7

Electrocardiograma ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Taquicardia sinusal Bloqueo incompleto de rama derecha Desviación del eje a derecha S1Q3T3

Ecocardiograma ,[object Object],[object Object],[object Object],[object Object],[object Object]

Angiotac ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Anticoagulación ,[object Object],[object Object],[object Object]

Filtro de vena cava ,[object Object],[object Object],[object Object],[object Object]

Tombolisis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Thrombolytic therapy of pulmonary embolism: a meta-analysis J Am Coll Cardiol 2002 Nov 6;40(9):1660-7

Trombolisis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],N Engl J Med 2002 Oct 10;347(15):1143-50

Contraindicaciones Absolutas Historia de ACV hemorragico Neoplasia cerebral activa < 2 m Qx cerebral o trauma Sangrado activo o reciente (<6 m) Relativas Diatesis hemorragicas Hipertensión severa sistólica (>200 mmHg o diastólica >110 mmHg) ACV no hemorrágico en los últimos 2 meses Qx ultimos 10 días Trombocitopenia (<100.000)

[object Object],[object Object],[object Object],[object Object],Massive pulmonary embolism. Circulation. 2006 Jan 31;113(4):577-82

Embolectomia ,[object Object],[object Object]

Embolectomia por cateter ,[object Object]

Embolectomía Quirúrgica ,[object Object],[object Object],[object Object],[object Object],[object Object],Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest. 2006 Apr;129(4):1043-50.

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