Fabio Salvi - sigg.it · Timmons S et al. Age Ageing 2003. CLINICAL PICTURE (2) Morrone D, Morrone...
Transcript of Fabio Salvi - sigg.it · Timmons S et al. Age Ageing 2003. CLINICAL PICTURE (2) Morrone D, Morrone...
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Fabio Salvi
U.O.C. Geriatria, Accettazione Geriatrica, Centro di Ricerca
per l’Invecchiamento; IRCCS INRCA, Ancona
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OUTLINE
• Epidemiologia
• Clinica
– “Mind the PE”
• Diagnosi
– Clinical Predictors Rules
– D-dimero
• Risk stratification
– Il ruolo dell’ecografia
– Home Treatment
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Kline JA, Kabrhel C. J Emerg Med 2015Heit JA, et al J Thromb Thrombolysis 2016
EPIDEMIOLOGIA
• Prevalenza di EP in PS: 1 su 400-1500 pazienti
• Incidenza di EP (in PS): aumenta con l’età delpaziente (da 1 su 10.000 pazienti nella terza decadedi vita a 1 su 200 pazienti nella nona decade di vita)
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DATI FLUSSO EmUr
0
10
20
30
40
50
60
70
80
32%
519431 accessi nei PS/PPI della Regione Marche, anno 2015
10.8%12.8%
8.3%
65-74 75-84 85+
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OUTLINE• Epidemiologia
• Clinica
– “Mind the PE”
• Diagnosi
– Clinical Predictors Rules
– D-dimero
• Risk stratification
– Il ruolo dell’ecografia
– Home treatment
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Agnelli G, Becattini C. N Engl J Med 2010
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Laack TA, Goyal DG. Emerg Clin N Am 2004
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CLINICAL PICTURE
EP should be suspected in all patients who present with new orworsening dyspnea, chest pain, or sustained hypotensionwithout an alternate obvious cause
Unexplained tachycardiaNew onset tachyarrhythmia
ESC Guidelines. Eur Heart J 2014
Dolore toracico pleuritico: improvvise edintense fitte, lancinanti o urenti inconcomitanza con gli atti respiratori; èesacerbato da respiri profondi, tosse,starnuto e risate. Se l’infiammazione è vicinaal diaframma il dolore può essereriferito/irradiato al collo o alla spalla.
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GERIATRIC PITFALLS
Sintomo Confondente
Dispnea/tosse/dolore toracico Comorbilità
Tachicardiab-bloccanti (calcio-antagonisti)Febbre/sepsi (concomitante)
Disidratazione
Emottisi Neoplasie, TAO/NAO
Sincope Caduta
Edema arto/i inferiore/i Scompenso cardiaco, IVC
Ipossia/Ipocapnia BPCO (ipercapnica)
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E IL DELIRIUM?
Carrascosa MF, et al. Mayo Clin Proc 2009
Soysal P, Isik AT. J Am Geriatr Soc 2014
Shaw JE, Belfield PW. Postgrad Med J 1991
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CLINICAL PRESENTATION
Timmons S et al. Age Ageing 2003
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CLINICAL PICTURE (2)
Morrone D, Morrone V. Korean Circ J 2018
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Prandoni P et al. N Engl J Med 2016
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Costantino G et al. JAMA Intern Med 2018
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EP & pneumonia/BPCO
Aleva FE, et al. Chest 2017Rohacek M, et al. PlosOne 2012
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OUTLINE• Epidemiologia
• Presentazione Clinica
– “Mind the PE”
• Diagnosi
– Clinical Predictors Rules
– D-dimero
• Risk stratification
– Il ruolo dell’ecografia
– Home treatment
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Kline JA, Kabrhel C. J Emerg Med 2015
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WELLS SCORE
Corrigan D, et al. Clin Exp Emerg Med 2016
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GENEVA SCORE
Corrigan D, et al. Clin Exp Emerg Med 2016
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QUALE USARE?
Harder EM, et al. Clin Chest Med 2018
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Kline JA, Kabrhel C. J Emerg Med 2015
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PERC
Kline JA, Kabrhel C. J Emerg Med 2015
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Nemec M et al. Acad Emerg Med 2010
D-dimero
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D-dimero
Tick LW et al. J Intern Med 2008
0
10
20
30
40
50
60
70
80
≤50 51-60 61-70 71-80 >80
Douma RA, et al. BMJ 2010Schouten HJ, et al. BMJ 2013
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IMAGING
ANGIO-TC POLMONARE TRIPLE RULE OUT
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OUTLINE• Epidemiologia
• Presentazione Clinica
– “Mind the PE”
• Diagnosi
– Clinical Predictors Rules
– D-dimero
• Risk stratification
– Il ruolo dell’ecografia
– Home treatment
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RISK STRATIFICATION
ESC Guidelines. Eur Heart J 2014
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ALGORITMO ESC GL
ESC Guidelines. Eur Heart J 2014
+CUS
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ECOGRAFIA & PE
•Venous US (CUS)
•Echocardiography– RH strain
– RV/LV ratio
– Abnormal/paradoxical septal motion
– RH strain curve for TR/insufficiency
•Lung scan– Pneumonia
– Pulmonary infarct
– Pleural effusion
Fields JM, et al. J Am Soc Echocardiogr 2017
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Nazerian P, et al. Acad Emerg Med 2016
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Nazerian P, et al. Acad Emerg Med 2016
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ALGORITMO PE STABILE
ESC Guidelines. Eur Heart J 2014
UltraSound
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TERAPIA (ALGORITMO)
ESC Guidelines. Eur Heart J 2014
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PESI/sPESI
ESC Guidelines. Eur Heart J 2014
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HOME TREATMENT
Zondag W, et al. Eur Resp J 2013
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HOT-PE TRIAL
Basco S, et al. Thromb Haemost 2016
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TAKE-HOME MESSAGES
• Mind the PE
Sospettare (sempre)
Verificare (il giusto)
• Mind the echo
CUS
Heart
Lung
• Mind the Home possibility
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