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Embolia polmonare

Generalità

L’embolia polmonare consiste nella migrazione al circolo polmonare di materiale che causa occlusione di una o più arterie polmonari. Gli emboli provengono nella maggior parte dei casi dagli arti inferiori attraverso la vena cava, più raramente dagli arti superiori o dalle cavità cardiache di destra in seguito a infarto miocardico o endocardite. Nella tromboembolia polmonare, di gran lunga la forma più comune di embolia polmonare, gli emboli sono costituiti da materiale trombotico. Più raramente il materiale trombotico può essere costituito da midollo osseo (embolia grassosa), dopo frattura delle ossa lunghe; da aria (embolia  a gassosa) in seguito a traumi o interventi chirurgici, come complicanza delle immersioni subacquee, infine, da liquido amniotico, condizione rara gravata da un’elevata mortalità, che può verificarsi in occasione di un travaglio laborioso o durante un parto cesareo. La trombosi in situ delle arterie polmonari, ovvero la formazione in loco di trombi, è una evenienza rara ma possibile, per esempio in soggetti con anemia falciforme o nei tossicodipendenti, in seguito a iniezione endovenosa di talco, usato come sostanza da taglio dell’ eroina, o in condizioni settiche. Nel 50% dei pazienti affetti da embolia polmonare è possibile diagnosticare una trombosi venosa profonda degli arti inferiori o del distretto della vena cava inferiore. Pertanto, la trombosi venosa profonda e  l’embolia polmonare vengono identificate come un’unica patologia il tromboembolismo venoso (TEV).

Epidemiologia

La tromboembolia polmonare rappresenta la terza patologia cardiovascolare acuta più frequente dopo le sindromi coronariche acute e l’ictus. Non è facile definire l’incidenza dell’ embolia polmonare per il mancato sospetto clinico, le difficoltà diagnostiche proprio di questa malattia. Di conseguenza una quota consistente di embolia polmonare non è diagnosticata in vita, come documentato da casistiche autoptiche che riportano percentuali elevate di mancata diagnosi prima del decesso. L’incidenza stimata in Italia è di 60.000 nuovi casi/anno. Negli studi autoptici la prevalenza di embolia polmonare non sospettata, sia fatale sia come concausa di morte, si aggira intorno al 3-8%.

Fattori di rischio

I fattori di rischio possono essere distinti in danni ereditari o acquisiti. 

Fattori di rischio acquisiti.

Rischio elevato:

  • trauma maggiore e/o fratture
  • chirurgia maggiore (ortopedica o generale)
  • trauma midollare

Rischio moderato:

  • neoplasie
  • catetere venoso centrale
  • terapia ormonale (contraccettiva o sostitutiva)
  • chirurgia artroscopica
  • pregresso tromboembolismo venoso
  • scompenso cardiaco o insufficienza respiratoria cronica
  • gravidanza o puerperio
  • paralisi postictale
  • trombofilia molecolare

 

Rischio basso:

  • allettamento >3 giorni
  • immobilizzazione
  • gravidanza
  • vene varicose

Fattori di rischio ereditari:

  • deficit di antitrombina
  • proteina di proteica C
  • deficit di proteina S
  • fattore di V Leiden


Sintomi

 

Le manifestazioni cliniche dell’embolia polmonare sono piuttosto aspecifiche e coprono un ampio spettro di gravità. Possono presentarsi pazienti paucisintomatici o addirittura asintomatici e pazienti con esordio drammatico con instabilità emodinamica fino allo shock o all’ arresto cardiorespiratorio. 

I sintomi principali sono:

  • nessun sintomo
  • dispnea (a riposo o da sforzo, ingravescente o improvvisa)
  • dolore toracico pleuritico
  • tosse
  • lipotimia/sincope
  • shock
  • dolore toracico anginoso
  • emottisi
  • arresto cardiaco
  • cardiopalmo

Segni:

  • nessun segno
  • tachipnea
  • tachicardia
  • segni di TVP (edema unilaterale degli arti inferiori)
  • cianosi
  • febbre


Diagnosi

Il sospetto di embolia polmonare andrebbe posto in tutti i pazienti che riferiscono dolore toracico, dispnea o ipotensione protratta in assenza di chiare cause alternative. In generale, il sospetto clinico di embolia polmonare viene confermato dagli accertamenti diagnostici oggettivi solo nel 20% dei casi.

  • elettrocardiogramma ECG
  • radiografia del torace
  • emogasanalisi arteriosa

possono fornire elementi di sospetto per la diagnosi di embolia polmonare, ma non sono metodiche sufficientemente sensibili né specifiche per la definitiva conferma diagnostica. La loro indubbia utilità clinica risiede nella possibilità di poter escludere diagnosi alternative.

La diagnosi oggettiva di embolia polmonare necessità di indagini in grado di studiare la vascolarizzazione e/o la perfusione polmonare, con esposizione a mezzo di contrasto, radiazioni ionizzanti o manovre invasive. Il percorso diagnostico ottimale prevede, come primo momento, la valutazione della probabilità pre-test di embolia polmonare, stimata implicitamente dal clinico esperto o tramite l’impiego di modelli validati in studi clinici che prendono in considerazione le caratteristiche della presentazione clinica.

Percorso diagnostico

Il percorso diagnostico nei pazienti emodinamicamente instabili  e in quelli stabili appare differente:

  • nei pazienti emodinamicamente instabili le condizioni cliniche potrebbero non consentire l’esecuzione degli esami diagnostici, che peraltro potrebbero non essere prontamente disponibili. In questi pazienti la dimostrazione di sovraccarico ventricolare destro acuto l’ecocardiografia effettuata a letto del paziente può essere sufficiente per iniziare il trattamento, rimandando l’esecuzione di altri esami diagnostici all’avvenuta stabilizzazione emodinamica o al momento in cui gli stessi siano disponibili
  • Nei presenti emodinamicamente stabili con bassa probabilità clinica pre-test, la diagnosi di embolia polmonare può essere esclusa senza ulteriori accertamenti in presenza di normali livelli di D-dimero (mediante metodica ultrasensibile ELISA):
  • l’incidenza di embolia  polmonare a 3 mesi in pazienti con pasta probabilità clinica pre-test e di D-dimero negativo non trattati con terapia anticoagulante è inferiore allo 0,2%;
  • l’esclusione della diagnosi di embolia polmonare in pazienti con probabilità​ clinica intermedia sulla base del D-dimero ha una ridotta specificità in corso di gravidanza, nei pazienti ospedalizzati, negli anziani o in pazienti affetti da neoplasia, per cui risulta utile in questi contesti clinici solo se negativo. Nei pazienti emodinamicamente stabili con elevata probabilità clinica con livelli di D-dimero al di sopra del limite di normalità, indicata all’esecuzione di un Angio TC del torace che ha potere predittivo negativo pari al 95%. 


Terapia

Il trattamento dell’embolia polmonare si compone di tre momenti:

  • terapia iniziale, o della fase acuta, nei primi 5-7 giorni dalla diagnosi
  • terapia di lungo termine, solitamente i primi 3 mesi
  • terapia estesa ovvero i primi tre mesi per tutti quei pazienti che presentano un rischio di recidiva particolarmente elevata.

Terapia iniziale

Lo scopo primario della terapia iniziale dell’embolia polmonare è ridurre la mortalità, che risulta essere massima nelle prime 48 ore dalla diagnosi. Pertanto, in presenza di alto sospetto clinico, è indicato iniziare il trattamento con eparina in attesa della conferma diagnostica. La terapia iniziale deve essere modulata in base alla severità dell’embolia polmonare. Risulta quindi essenziale un percorso specifico per pazienti ad alto rischio, ovvero in shock o ipotensione protratta.

Pazienti emodinamicamente instabili-Embolia polmonare ad alto rischio

I pazienti con embolia polmonare ad alto rischio di mortalità, che rappresentano circa il 10- 15% dei pazienti con embolia polmonare, dovrebbero ricevere terapia trombolitica in assenza di controindicazioni. Il sovraccarico ventricolare destro acuto è ritenuto responsabile dell’elevata mortalità osservata in questi pazienti. La terapia trombolitica è in grado di ottenere una più rapida riduzione della pressione polmonare e del conseguente sovraccarico ventricolare destro e una più rapida riperfusione polmonare rispetto all’eparina. La terapia trombolitica si associa a un  rischio pari al 10% circa di emorragie maggiori e al 3% circa di emorragia cerebrale. L’evidenza che tale trattamento possa ridurre la mortalità intraospedaliera deriva da una meta-analisi di studi randomizzati.

Pazienti emodinamicamente stabili-Embolia polmonare rischio non rilevato. Circa il 90% dei pazienti con embolia polmonare rientra in questa categoria. Tutti i pazienti con embolia polmonare a rischio non elevate devono ricevere terapia anticoagulante a dose terapeutica. ​L’uso di eparina a basso peso molecolare nel trattamento dell’embolia polmonare in pazienti emodinamicamente stabili è altrettanto efficace e sicuro di quello con eparina non frazionata.

 

Terapia a lungo termine

Tutti i pazienti con diagnosi di embolia polmonare necessitano di terapia anticoagulante di lungo termine per completare il trattamento dell’ episodio acuto e ridurre il rischio di recidive precoci. I farmaci anticoagulanti orali sono farmaci di scelta per questa fase del trattamento eccetto in pazienti con neoplasia. La scelta dell’ anticoagulante orale sarà basata principalmente sulle caratteristiche del paziente e  sulla morbilità.

 

Terapia estesa

La terapia estesa è il trattamento anticoagulante protratto oltre i primi 3- 6 mesi per il trattamento delle TEV. Scopo di questa terapia è la prevenzione delle recidive. Trattandosi di una terapia solitamente di lunga durata i farmaci orali sono gli agenti di scelta.

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Pneumotorace

Lo pneumotorace è una patologia piuttosto frequente, ha una distribuzione per età che non conosce frammentazione per cui è tanto frequente nel giovane quanto nell’adulto, soprattutto se quest’ultimo è affetto da BPCO oppure da patologia degenerativa degli epiteli come l’enfisema bolloso.(Continua)

Dolore toracico

Il dolore toracico è un sintomo molto frequente, che può manifestarsi come una pugnalata, undolore sordo, come un fastidio o un dolore tra il collo e l’addome superiore. In molti casi la diagnosi è rapida e può salvare la vita. Il 39% della popolazione riferisce di avere avvertito dolore toracico in un certo momento della vita. (Continua)

 

Sarcoidosi: sintomi, diagnosi e cura

La sarcoidosi è una malattia cronica di cui non si conosce la causa. E’ caratterizzata dalla presenza di granulomi, di accumuli di cellule, nei tessuti degli organi colpiti e dall’alterazione della normale struttura dei tessuti. L’organo che viene più facilmente colpito dalla sarcoidosi è il polmone, tuttavia.(Continua)

Tubercolosi (TBC) 

La tubercolosi (TBC) è una patologia infettiva e contagiosa, si trasmette da persona a persona per via aerea da pazienti con malattia polmonare attiva. I sintomi più comuni sono: tosse, emottisi, dolore pleurico. (Continua)

Eparina

L’eparina è un principio attivo anticoagulante, in grado – come tale – di rallentare o interrompere il processo di coagulazione del sangue; è invece incapace di promuovere la dissoluzione dei coaguli già formati, che viene altrimenti favorita dai prodotti di un’altra categoria farmaceutica, quella dei fibrinolitici. (Continua)

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