PULMONER EMBOLİDE TROMBOLİTİK TEDAVİ VE KONVANSİYONEL TEDAVİ ETKİNLİĞİNİN 10. GÜNDE KARŞILAŞTIRILMASI

Year 2017, Volume: 31 Issue: 3, 135 - 144, 01.12.2017

Gökhan Aykun Mükremin Er Ayşegül Karalezli H.canan Hasanoğlu

Abstract

Amaç: Trombolitik tedavinin hastaya sadece ilk
birkaç gün fayda sağladığı, 1. haftadan sonra ise
sadece antikoagülan tedavi alanların da benzer
trombüs erime oranlarına sahip oldukları düşünülmektedir.
Bu çalışmanın amacı trombolitik tedavinin
10. gününde hastaların klinik parametrelerine
ve Pulmoner Arter BT Obstrüksiyon İndeksi açılma
oranlarına etkisinin olup olmadığının araştırılmasıdır.

Yöntem ve Gereç: Çalışmaya pulmoner tromboemboli
tanısı konmuş 28 olgu alındı. Trombolitik
tedavi verilmesinin uygun görüldüğü 15 hasta
çalışma grubuna (grup 1), kalan 13 hasta ise
konvansiyonel tedavi(antikoagülan tedavi) grubuna
(grup 2) alındı. Tedavinin semptomların başlamasından
sonraki ilk 14 günde başlandığı hastalardan
trombolitik (r-TPA) verilenler grup 3, verilmeyenler
grup 4 olarak planlandı. Çalışma grubundaki hastalara
tanı konulduğu anda protokole göre trombolitik
tedavi uygulandı ve ardından antikoagülan
tedavi ile devam edildi. Kontrol grubundaki
hastalara sadece antikoagülan tedavi verildi. Geliş
sırasında ve 10. günde pulmoner BT anjiyografi,
transtorasik ekokardiyografi, arteryel kan gazı
çalışıldı. PABTOİ hesaplandı. Veriler tedaviden önce
ve tedaviden sonra 10. günde gruplar arasında
karşılaştırıldı. Bulgular: Gruplar arasında başlangıç kriterlerinde
istatistiksel olarak anlamlı farklılık saptanmadı.
Grup 1’de 10. günde %52.8±25.5’lük açılma oranı
elde edilirken, grup 2’de bu oran %42.5±20.0
olarak saptandı. Grup 3’de10. günde açılma oranı
%58.4±24.5’e ulaşırken, grup 4‘de bu oran
%42.2±22.2 bulundu. Tedavinin 10. gününde grup
3’deki hastalarda grup 4’e göre PO2, SaO2 ve PAB
değerlerinde anlamlı düzelme bulundu (p<0.05).
Sonuç: Sonuç olarak, pulmoner embolinin akut
döneminde yararı bilinen trombolitik tedavinin,
yalnız konvansiyonel antikoagülan verilen gruba
göre daha iyi BT açılma oranları, AKG ve EKO
bulgularının olması tedavinin 10. gününde bile
yararlı olduğunu göstermiştir.

Keywords

Pulmoner emboli, pulmoner BT anjiyografi, r-TPA

COMPARISON OF THROMBOLYTIC AND CONVANSIONAL TREATMENT EFFICIENCY IN PULMONARY EMBOLISM ON THE 10TH DAY OF TREATMENT

Abstract

Aim: Benefit of thrombolytic therapy for the
patients with pulmonary embolism is thought to
be in only the first few days and it’s considered
that after the first week anticoagulation therapy
has similar rates of resolution. The purpose of the
study is to investigate the effect of thrombolytic
therapy on the patient's clinical parameters and
Pulmonary Artery CT Obstruction Index opening
rates on the tenth day.
Material and Methods: In this study, 28
pulmonary embolism cases were investigated.
Taken in to consideration clinical, radiographic,
echocardiographic, biochemical findings, and
contraindications to thrombolytic therapy, 15
patients enrolled to the thrombolytic therapy
group (group 1) and the remaining 13 patients
were included in the conventional therapy (group
2).Patients given thrombolytic therapy(r-TPA) in
the first 14 days after pulmonary embolism was
planned as group 3 and treated with
anticoagulants only as group 4. Pulmonary CT
angiography, transthoracic echocardiography
(ECHO), arterial blood gasses were studied on
admission and tenth day. PACTOI was calculated
from pulmonary CT angiography. Results: Differences were insignificant between
the groups for the initial criteria. Opening rate on
the tenth day was 52.8%±25.5 in group 1 and
42.5%±20.0 in group 2. In patients of group 3
opening rate was 58.4%±24.5 on the tenth day,
whereas in group 4 it was 42.2%±22.2. Significant
improvements on PO2, SaO2 and PAP was seen in
group 3 patients at the tenth day when compared
with group 4 (p<0.05).
Conclusion: As a conclusion it is shown that
patients receiving thrombolytic therapy had better
PACTOI and ABG and ECHO findings at the tenth
day.

Keywords

Pulmonary embolism, pulmonary CT angiography, r-TPA

References

• 1. Dahnert W. Pulmonary thromboembolic disease. In: Dahnert W, ed. Radiology Review Manual. 4th Edition. Philadelphia. Lippincott Williams & Wilkins. 1999; 431-2.
• 2. Stein PD, Henry JW. Prevalence of Acute Pulmonary Embolism Among Patients in a General Hospital and at Autopsy. Chest 1995; 108:978-81
• 3. Hirsh J, Guyatt G, Albers GW, Harrington R, Schünemann HJ. Antithrombotic and thrombolytic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:71-109
• 4. Konstantinides S, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) 2014; 35: 3033–80 doi:10.1093/ eurheartj/ ehu283
• 5. Kearon C, Akl EA, Comerota AJ, Prandoni P, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic Therapy for VTE Disease Antithrombotic Therapy for VTE: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141(2_suppl):419-94
• 6. Howard Luke S. Thrombolytic therapy for submassive pulmonary embolus? PRO viewpoint. Editorial. Thorax 2014; 69(2):103-5. doi: 10.1136/thoraxjnl-2013-203413. Epub 2013 Apr 26.
• 7. Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Management Strategies and Prognosis of Pulmonary Embolism-3 Trial Investigators. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002; 347:1143-50
• 8. Sasahra AA, Bell WR, Simon TL, Stengle JM, Sherry S. The phase II urokinase-streptokinase pulmonary embolism trial: a national cooperative study. Thromb Diath Haemorrh 1975; 33:464-76
• 9. Konstantinides S, Tiede N, Geibel A, Olschewski M, Just H, Kasper Wolfgang. Comparison of Alteplase versus Heparin for Resolution of Major Pulmonary Embolism. Am J Cardiol 1998; 82:966–70
• 10. Dalla-Volta S, Palla A, Santolicandro A, Giuntini C, Pengo V, Visioli O, et al. PAIMS 2: alteplase combined with heparin versus heparin in the treatment of acute pulmonary embolism. Plasminogen activator Italian multicenter study 2. J Am Coll Cardiol 1992; 20:520–6
• 11. Çelenk Ç, Öztürk A. Pulmoner Emboli Tanısında Spiral Bilgisayarlı Tomografi Pulmoner Anjiografi. Turk J Med Sci 2005; 25:197-203
• 12. Langan CJ, Weingart S. New Diagnostic and Treatment Modalities for Pulmonary Embolism: One Path through the Confusion. Mt Sinai J Med 2006; 73:528-41
• 13. Qanadli SD, Hajjam ME, Vieillard-Baron A, Joseph T, Mesurolle B, Oliva VL et al. New CT index to quantify arterial obstruction in pulmonary embolism: Comparison with angiographic index and echocardiography. Am J Roentgenol. 2001; 176:1415–20
• 14. Wood KE. Major Pulmonary Embolism: Review of a Pathophysiologic Approach to the Golden Hour of Hemodynamically Significant Pulmonary Embolism. Chest 2002; 121:877- 905
• 15. Smulders YM. Contribution of pulmonary vasoconstriction to haemodynamic instability after acute pulmonary embolism. Implications for treatment? Neth J Med 2001; 58:241-7
• 16. Arseven O, Sevinç C, Alataş F, Ekim N, Erkan L, Fındık S. Türk Toraks Derneği Pulmoner Tromboembolizm Tanı ve Tedavi Uzlaşı Raporu. Journal of Thorax 2009; 10:7-47
• 17. Suga K, Yasuhiko K, Iwanaga H, Tokuda O, Matsunaga N.Relation between lung perfusion defects and intravascular clots in acute pulmonary thromboembolism: assessment with breath-hold SPECT-CT pulmonary angiography fusion images. Eur J Radiol. 2008; 67:472-80
• 18. Ghuysen A, Ghaye B, Willems V, Lambermont B, Gerard P, Dondelinger RF, D'Orio V. Computed tomographic pulmonary angiography and prognostic significance in patients with acute pulmonary embolism. Thorax 2005; 60:956–61
• 19. Meer RW, Pattynama PM, Strijen MJ, BergHuljsmans AA, Hartmann IJ, Putter H, et al. Right Ventricular Dysfunction and Pulmonary Obstruction Index at Helical CT: Prediction of Clinical Outcome during 3-month Follow-up in Patients with Acute Pulmonary Embolism. Radiology 2005; 235:798–803
• 20. Wu AS, Pezzullo JA, Cronan JJ, Hou DD, MayoSmith WW. CT Pulmonary Angiography: Quantification of Pulmonary Embolus as a Predictor of Patient Outcome--Initial Experience. Radiology 2004; 230(3):831–5
• 21. Metafratzi ZM, Vassiliou MP, Maglaras GC, Katzioti FG, Constantopoulos SH, Katsaraki A, et al. Acute Pulmonary Embolism: Correlation of CT Pulmonary Artery Obstruction Index with Blood Gas Values. AJR 2006; 186:213–9
• 22. Çildağ MB, Karaman CZ. Pulmoner Tromboemboli Tanısında Bilgisayarlı Tomografik Pulmoner Anjiografi Obstrüksiyon İndeksi ile Geneva Klinik Skorlamasının İlişkisi. Turk Toraks Der 2009; 10:4-8
• 23. McIntyre KM, Sasahara AA. The hemodynamic response to pulmonary embolism in patients without prior cardiopulmonary disease. The American Journal of Cardiology 1971; 28:288- 94
• 24. McDonald IG, Hirsh J, Hale GS, O’Sullivan EF. Major pulmonary embolism, a correlation of clinical findings, haemodynamics, pulmonary angiography, and pathological physiology. British Heart Journal I972; 34:356-64
• 25. Harris T, Meek S. When should we thrombolyse patients with pulmonary embolism? A systematic review of the literature. Emerg Med J 2005; 22:766–71
• 26. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353:1386–9 doi:10.1016/S0140- 6736(98)07534-5
• 27. Goldhaber SZ. Thrombolysis in Venous Thromboembolism. Chest 1990; 97:176-80
• 28. Meyer G, Vicaut E, Danays T, et al. for the PEITHO Investigators. N Engl J Med 2014; 370:1402-11