Jerjes-Sánchez C, Villagómez A, Palomar-Lever A

Language: Spanish
References: 5
Page: 41-43
PDF size: 36.99 Kb.

ABSTRACT

All patients at low risk of death or major cardiovascular event secondary to minor pulmonary thromboembolism (PT), without right ventricular dysfunction (RVD), and with a normal systemic perfusion should receive heparin plus oral anticoagulants. Whether the mortality risk associated to massive PT is high, there is a severe pulmonary arterial hypertension (PAH), and RVD, either pharmacological or mechanical reperfusion must be attempted. Occasionally, a combined reperfusion strategy improves evolution of the patient. Non-fractionated heparin (NFH) should be started with an IV bows of 80IU/Kg continuing with an IV continuous infusion of 18 IU/Kg/hour in order to maintain the partial activated thromboplastin time 1.5 to 2.5 times the time of the control. This infusion is maintained until at least two therapeutical INR are reached with oral anticoagulants. Low molecular weight heparins can be used is patients with low-risk PT. They diminish the in-hospital period improving the quality of life of the patient. Oral anticoagulants are initiated at the first or second day until INR reaches the therapeutical range (between 2.0 y 3.0). Patients without previous cardiovascular disease and with a massive PT may be candidates to thrombolysis if there are not absolute contraindications. In patients with PT without hemodynamical dysfunction thrombolysis is not useful; in cases with sub-massive PT its use is controversial. Streptokinase is given in an IV infusion of 1,500,000 IU in 1 or 2 hours; recombinant tissue plasminogen activator is given either as a continuous peripheral infusion during 2 hours or as an IV bolus of 20 mg followed by an IV infusion of 80 mg during 1 hour. Fast infusions improve cardiopulmonary hemodynamics and right ventricular remodeling. Perhaps, rescue thrombolysis is an alternative in some selected patients. There is not enough evidence to support any recommendations about catheter directed embolectomy.

REFERENCES

1. Guías de la Sociedad Mexicana de Cardiología para la estratificación, diagnóstico y tratamiento de la tromboembolia pulmonar aguda. Jerjes–Sánchez C, Elizalde GJ, Sandoval J, Gutiérrez–Fajardo P, Seoane GLM, Ramírez–Rivera A, Bautista E. Arch Cardiol Mex 2004; Arch Cardiol Mex 2004;74(supl):S548– S555.

2. Task Force on Pulmonary Embolism, European Society Cardiology. Guidelines on diagnosis and management of acute pulmonary embolism. Eur Heart J 2000;21:1301-1336.

3. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et al. Prevention of Venous Thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:338S-400S.

4. Raschke RA, Gollihare B, Peirce JC. The effectiveness of implementing the weight-based heparin nomogram as a practice guideline. Arch Intern Med 1996;156:1645-1649.

5. Ansell J, Hirsch J, Poller L, Bussey H, Jacobson A, Hylec E. The pharmacology and management of vitamin K antagonist. The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004;136:204S–233S.