PE

Question 1

Strongest risk factor for the development of VTE?

Answer 1

Myocardial infarction within 3 months

Question 2

What is the definition of a massive/unstable PE?

Answer 2

SBP<90

High mortality risk

Question 3

How common is CTEPH?

Answer 3

1.5% of patient with unprovoked VTE within 2 yrs

Question 4

After 12 months the prevalence of recurrent PE following cessation of anticoagulation is approximately?

Answer 4

10%

Increased rates in:

• Patients who don’t reach therapeutic anticoagulation
• Active cancer = 15%/yr
• Multiple VTEs
• Unprovoked VTE -30% at 5yrs
• OCP continuation
• Proximal DVT
• Elevated D-dimer
• males
• patients with APL syndrome or FVL heterozygosity

Question 5

Strongest predisposing factors for VTE

Answer 5

Fracture of the lower leg
Hospitalisation for HF or AF within 3/12
Hip or knee replacement with 3/12
Major trauma
MI within 3/12
Previous VTE
Spinal cord injury

Question 6

Should routine thrombophilia screening be preformed?

Answer 6

No

Only if:
Family history of VTE <45yrs first degree relatives
Multiple or unusual site
Warfarin induced skin necrosis - Protein C
Arterial thrombosis

Protein C and s, ATIII deficiency, FVL and prothrombin gene mutations

Question 7

Which test should be used to exclude PE?

Answer 7

Normal V/Q scan

Question 8

When should D-Dimer be used?

Answer 8

Low-mod pre-test probability

Question 9

What about CTPA?

Answer 9

Does overdiagnose PE and cannot exclude PE if clinical suspicion is high

Question 10

Should Venous dopplers be used?

Answer 10

30-50% of patients with a PE diagnosed with DVT

Question 11

Should TTEs be performed?

Answer 11

Can identify RV dysfunction in high risk PE patients - hypotension or shock

Question 12

Adverse prognostic factors for PE?

Answer 12

RV dysfunction = 2x mortality
RV thrombus
Co-Existent DVT
High BNP 
Hyponatraemia
High troponin
Lactate >2

Question 13

Noacs in PE compared to warfarin?

Answer 13

Lower rates of intracranial bleeds
NOT FOR OBESE >120kgs or BMI >40

Rivaroxaban or apixaban
LMWH followed by dabigatran
LMWH followed by Warfarin

Question 14

Duration of treatment?

Answer 14

Provoked PE = 3 months of treatment

Active Cancer = LMWH no stop date

Unprovoked
= High risk of bleeds = 3/12
= low risk = indefinite
Use aspirin in all patients with unprovoked PE when stopping anticoagulation therapy

Question 15

When should Thrombolysis be used?

Answer 15

Hypotensive patients