PE

Question 1

What further investigations are required in a patient with an unprovoked DVT or PE ?

Answer 1

History
FBC, Renal, liver, PT, aPTT.
Examination.
Do not investigate for cancer and less relevant symptoms or signs. 

Question 2

What is the simplified PESI score?

Answer 2

Age > 80
Cancer (diagnosed within last 12 months or undergoing treatment).
Chronic cardiopulmonary disease.
Heart rate >=110
Systolic BP<100
SATS <90

All worth 1 – low-risk =0, 1+ = high

Question 3

What is the 30 day mortality of a patient with a low risk sPESI score?

Answer 3

1%

sPESI score ≥1 = 30 day mortality of 11%

Question 4

What are the Hestia criteria?

Answer 4

Contraindications for OP PE management

Haemodynamic instability
Need for thrombolyses or embolectomy
Active bleeding or high risk of bleeding
>24 hours of oxygen to keep sats >90%
PE on anticoagulation.
Severe pain needing IV meds >24 hours.
Medical or social reason for hospital treatment >24hrs
CrCl <30
Severe liver impairment.
Pregnancy
History of heparin induced thrombocytopenia.

Question 5

When can and patient with a confirmed PE be managed as an outpatient?

Answer 5

sPESI 0
No exclusion criteria.

No specific assessment of bleeding risk is required in patients deemed low risk by risk stratification.

Measurement of RV: LV, ratio on CT or RV on echo is not required in low risk patients.

If RV dilation identified in patient, otherwise suitable for outpatient management, consider using BNP, Troponins I/S - if normal, then can be outpatient (consider alternative causes for trop rise)

Question 6

What further assessment should be carried out in a patient with PE considered low risk on sPESI?

Answer 6

Check for exclusion criteria for outpatient management.
Do not need specific assessment of bleeding risk or assessment of RV function.

Question 7

How should a patient with suspected PE be managed?

Answer 7

Investigation on the same day if feasible. Otherwise anticoagulation followed by outpatient imaging within 24 hours if deemed low risk

Question 8

How should patients with confirmed PE being treated as an outpatient be managed?

Answer 8

One of:
LMWH + dabigatran
LMWH + edoxaban
Apixaban (single agent)
Rivaroxaban (single agent)

Single agent options preferred

Verbal and written information on the signs and symptoms of recurrence, major bleeding and complications.

Formal review at least once during the first week.

Question 9

Mr B has been admitted to hospital with a PE. His sPESI score was 1 on arrival but is now 0. What should happen next?

Answer 9

Can be discharged - requires consultant review (or ST3 if not available) prior to discharge

Question 10

Mr B attends hospital with pleuritic chest pain and breathlessness. He had a hip operation in the last two weeks. He has no other past medical history. His observations are within the normal range. What is the next most appropriate step?

Answer 10

CTPA or interim anticoagulation while waiting CTPA

2 level Wells score:
3 clinical signs and symptoms of DVT.
3 alternative diagnosis less likely than PE
1.5 heart rate >100
1.5 immobilisation >3 days or surgery within 4 weeks
1.5 previous DVT or PE
1 haemoptysis
1 malignancy (treatment within the last 6 months or palliative)

If >4 then CTPA (or anticoagulation to bridge to CTPA)
If <=4 then d-dimer (give anticoagulation if wait >4hrs for result)

If d-dimer positive then CTPA/anticoagulation while waiting for CTPA
NB. if CTPA then negative consider leg ultrasound for DVT if suspect

Question 11

What makes up the Wells score for PE

Answer 11

2 level Wells score:
3 clinical signs and symptoms of DVT.
3 alternative diagnosis less likely than PE
1.5 heart rate >100
1.5 immobilisation >3 days or surgery within 4 weeks
1.5 previous DVT/PE
1 haemoptysis
1 malignancy (treatment within the last 6 months or palliative)

If >4 then CTPA (or anticoagulation to bridge to CTPA)
If <=4 then d-dimer (give anticoagulation if wait >4hrs for result)

Question 12

Mr X has a CTPA showing a PE. What further investigation should be carried out?

Answer 12

Bloods: FBC, Renal, liver, PT, aPTT
History and examination.
No need for cancer investigations, unless suspected from above.
If low risk as per sPESI, then no need for echo.

Question 13

Mr Z has a PE confirmed on CTPA. He has no other medical history and is low risk on stratification. How should he be treated?

Answer 13

Apixaban or Rivaroxaban single-agent
Otherwise LMWH for 5d with Dabigatran or Erdoxaban
Or LMWH with Warfarin until INR >2 on consecutive readings

Question 14

How should PE be managed in a patient with renal failure creatinine clearance less than 15?

Answer 14

LMWH or UFH
Can consider warfarin with above as bridge

Nb. CrCl 15-50: as per no renal impairment

Apixaban or Rivaroxaban single-agent
Otherwise LMWH for 5d with Dabigatran or Erdoxaban
Or LMWH with Warfarin until INR >2 on consecutive readings

Question 15

How should a patient with confirmed PE and active cancer (receiving treatment, diagnosed within six months, recurrent, metastatic, or inoperable) be treated?

Answer 15

Consider DOAC
LMWH or warfarin with LMWH bridge if unsuitable

Treat for 3 to 6 months

Question 16

How should a patient with antiphospholipid syndrome and a PE be treated?

Answer 16

Warfarin with LMWH bridge

Question 17

How long should a patient with a PE be treated for if unprovoked?

Answer 17

Assess at three months.

NB for cancer this is 3 to 6 months

Question 18

Mr Z presents the hospital with chest, pain, breathlessness, and haemoptysis. What is the next most appropriate step?

Answer 18

History, examination and CXR
If likelihood of PE considered by doctor <15% use the PERC criteria to decide about further work up.

PERC CRITERIA all worth 1 (if any positive then can’t use to rule out PE). If all negative then PE<2%
Age >= 50
HR >= 100
SATS < 95
Unilateral leg swelling.
Haemoptysis
Surgery or trauma <= 4 weeks
Prior PE or DVT?
Oral contraceptive/hormone replacement.

Question 19

What are the PERC criteria?

Answer 19

PERC CRITERIA all worth 1 (if any positive then can’t use to rule out PE). If all negative then PE<2%
Age >= 50
HR >= 100
SATS < 95
Unilateral leg swelling.
Haemoptysis
Surgery or trauma <= 4 weeks
Prior PE or DVT?

Question 20

Mr T has signs and symptoms of both a DVT and PE.

What initial diagnostic investigation should be carried out?

Answer 20

Can be for either DVT or PE

Question 21

Should you wait for results of blood tests before starting treatment for a patient with confirmed PE?

Answer 21

No, but need to review within 24 hours

Question 22

How should a patient with PE and haemodynamic instability be managed?

Answer 22

UFH infusion and consider thrombolysis

Do not offer if RV dysfunction without haemodynamic instability

Question 23

Mr B has a PE. What is it very high risk of bleeding. How should he be managed?

Answer 23

IVC FILTER

Also, consider if failure of anticoagulation.

Must have strategy in place for removal.

Question 24

When should thrombophilia testing be considered in a patient with PE?

Answer 24

If unprovoked should consider antiphospholipid antibodies.
In unprovoked also consider hereditary thrombophilia screening if first-degree relative with DVT or PE

Question 25

Jane is pregnant. She presents to the ED with chest pain and breathlessness. She has no calf swelling. observations are normal. chest. X-ray shows slight opacification in the right lower zone. What is the next appropriate investigation?

Answer 25

CTPA
- if suspicion of DVT than Doppler would be performed first
- Otherwise, CTPA or VQ. If abnormality on CXR then CTPA preferred

Nb. VQ scan has slightly higher risk of childhood cancer, but slightly lower risk of maternal breast cancer always should be discussed with the woman.

Question 26

What is risk of recurrence of VTE in pt with unprovoked VTE after stopping anticoagulant?

Answer 26

10% first year then 5% every year after

Question 27

What proportion of patients with PE develop CTEPH?

Answer 27

3.8% over 10 years

Question 28

How should pt with PE who is 130kg be managed?

Answer 28

Anticoag but with therapeutic level monitoring (do for <50kg or >120kg)

Question 29

Pt with PE has CrCl of 20ml/min. How should he be managed?

Answer 29

For CrCl 15-50

Apixaban or rivaroxaban

Or LMWH for at least 5 days followed by: edoxaban or dabigatran if estimated creatinine clearance is 30 ml/min or above

Or LMWH or UFH, given concurrently with a VKA for at least 5 days or until the INR is at least 2.0 in 2 consecutive readings, followed by a VKA on its own.

Question 30

How should pt with CrCl 12 with PE be managed?

Answer 30

For CrCl <15:

LMWH
or
UFH
or
LMWH or UFH concurrently with a VKA for at least 5 days or until the INR is at least 2.0 in 2 consecutive readings, followed by a VKA on its own.

Question 31

When should PE undergo thrombolysis?

Answer 31

Haemodynamic instability
- BP<90 or drop ≥40 for 15mins
- BP<90 + end-organ hypoperfusion (e.g. elevated lactate, confusion, anuria)

Consider if marked dyspnoea, hypoxaemia, elevated trop, RV dysfunction on echo, RV enlargement on echo/CT, free-floating t thrombus

Question 32

What are CIs to thrombolysis for PE?

Answer 32

Absolute
- History of haemorrhagic stroke
- Active brain malignancy
- Brain surgery/trauma <2months
- Internal bleeding <6months

Relative
- Bleeding diathesis
- Uncontrolled HTN (220/110)
- Non-haemorrhagic stroke <2months
- Surgery <10days
- Plt <100

Question 33

How should pt with intermediate-high risk of PE be managed?

Answer 33

In hospital with LMWH over 2-3 days to ensure remain stable before switching to oral

Question 34

How and how long should pregnant pt with PE be treated?

Answer 34

LMWH until 6 weeks post-natal or 3 months total (whichever is longer)