Pulmonary embolism

Question 1

What are potential features of pulmonary embolism?

Answer 1

Potential features include chest pain (typically pleuritic), dyspnoea, haemoptysis, tachycardia, and tachypnoea.

In respiratory examination, the chest will classically be clear, but real-world findings may vary.

Question 2

What percentage of patients present with the textbook triad of pulmonary embolism symptoms?

Answer 2

Around 10% of patients present with the textbook triad of pleuritic chest pain, dyspnoea, and haemoptysis.

Question 3

What did the PIOPED study in 2007 reveal about the frequency of symptoms in pulmonary embolism?

Answer 3

The study found the following frequencies: Tachypnea (96%), Crackles (58%), Tachycardia (44%), Fever (43%).

Question 4

What does the Well’s criteria for diagnosing pulmonary embolism emphasize?

Answer 4

The Well’s criteria emphasize tachycardia rather than tachypnoea.

Question 5

What is the typical presentation of pulmonary embolism?

Answer 5

Few patients (around 10%) present with the textbook triad of pleuritic chest pain, dyspnoea, and haemoptysis.

Question 6

What are common clinical signs of pulmonary embolism according to the PIOPED study?

Answer 6

Tachypnea (96%), Crackles (58%), Tachycardia (44%), Fever (43%).

Question 7

What is the significance of the Well’s criteria in diagnosing pulmonary embolism?

Answer 7

The Well’s criteria use tachycardia rather than tachypnoea.

Question 8

What should be done for patients with symptoms suggestive of pulmonary embolism?

Answer 8

A history should be taken, examination performed, and a chest x-ray to exclude other pathology.

Question 9

What is the purpose of the pulmonary embolism rule-out criteria (PERC)?

Answer 9

All criteria must be absent to have a negative PERC result, ruling out PE.

Question 10

When should the PERC rule be applied?

Answer 10

When there is a low pre-test probability of PE (< 15%).

Question 11

What does a negative PERC result indicate?

Answer 11

It reduces the probability of PE to < 2%.

Question 12

What is the 2-level PE Wells score used for?

Answer 12

To assess the likelihood of pulmonary embolism.

Question 13

What points are assigned for clinical signs and symptoms of DVT in the 2-level PE Wells score?

Answer 13

3 points for clinical signs and symptoms of DVT.

Question 14

What indicates a ‘likely’ PE in the 2-level PE Wells score?

Answer 14

More than 4 points.

Question 15

What should be done if a PE is ‘likely’?

Answer 15

Arrange an immediate computed tomography pulmonary angiogram (CTPA).

Question 16

What should be done if a PE is ‘unlikely’?

Answer 16

Arrange a D-dimer test.

Question 17

What is the recommended initial lung-imaging modality for non-massive PE?

Answer 17

CTPA is now the recommended initial lung-imaging modality.

Question 18

What are the advantages of CTPA over V/Q scans?

Answer 18

Speed, easier to perform out-of-hours, reduced need for further imaging, and possibility of providing an alternative diagnosis.

Question 19

What is the sensitivity and specificity of D-dimers?

Answer 19

Sensitivity is 95-98%, but specificity is poor.

Question 20

What classic ECG changes are seen in pulmonary embolism?

Answer 20

Large S wave in lead I, large Q wave in lead III, and inverted T wave in lead III - ‘S1Q3T3’.

Question 21

What is the typical finding on a chest x-ray for pulmonary embolism?

Answer 21

Typically normal, but possible findings include a wedge-shaped opacification.

Question 22

What is the sensitivity and specificity of V/Q scans?

Answer 22

Sensitivity is around 75% and specificity is 97%.

Question 23

What are possible causes of mismatch in V/Q scans?

Answer 23

Old pulmonary embolisms, AV malformations, vasculitis, previous radiotherapy.

Question 24

What may be missed by CTPA?

Answer 24

Peripheral emboli affecting subsegmental arteries may be missed.

Question 25

What are the key changes in NICE guidelines for VTE management as of 2020?

Answer 25

The key changes include recommending direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, using DOACs in patients with active cancer, outpatient treatment for low-risk pulmonary embolism (PE) patients, and no longer recommending routine cancer screening following a VTE diagnosis.

Question 26

What is the current approach to outpatient treatment for low-risk PE patients?

Answer 26

Patients with a new diagnosis of PE who are deemed low-risk are increasingly managed as outpatients, supported by NICE guidance.

Question 27

What tool does NICE recommend for determining suitability for outpatient treatment?

Answer 27

NICE recommends using a ‘validated risk stratification tool’ to determine suitability for outpatient treatment, but does not specify which tool to use.

Question 28

Which score is supported by the 2018 British Society guidelines for outpatient treatment?

Answer 28

The Pulmonary Embolism Severity Index (PESI) score is supported for outpatient treatment.

Question 29

What are the key requirements for outpatient treatment in low-risk PE patients?

Answer 29

Key requirements include haemodynamic stability, lack of comorbidities, and support at home.

Question 30

What is the cornerstone of VTE management?

Answer 30

Anticoagulant therapy is the cornerstone of VTE management.

Question 31

What significant change occurred in the 2020 guidelines regarding anticoagulant therapy?

Answer 31

The 2020 guidelines increased the use of direct oral anticoagulants (DOACs) as first-line treatment.

Question 32

What should be offered first-line following a diagnosis of PE?

Answer 32

Apixaban or rivaroxaban (both DOACs) should be offered first-line following a diagnosis of PE.

Question 33

What is the recommended approach if neither apixaban nor rivaroxaban are suitable?

Answer 33

If neither are suitable, use LMWH followed by dabigatran or edoxaban, or LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin).

Question 34

What is the recommendation for patients with active cancer regarding anticoagulant therapy?

Answer 34

The new guidelines recommend using a DOAC unless contraindicated.

Question 35

What should be done if a patient has severe renal impairment?

Answer 35

In cases of severe renal impairment (e.g. < 15/min), use LMWH, unfractionated heparin, or LMWH followed by a VKA.

Question 36

What is the recommended duration of anticoagulation for all patients?

Answer 36

All patients should have anticoagulation for at least 3 months.

Question 37

How does the duration of anticoagulation differ for provoked vs unprovoked VTE?

Answer 37

For provoked VTE, treatment is typically stopped after 3 months (3 to 6 months for active cancer). For unprovoked VTE, treatment is typically continued for up to 3 additional months (i.e. 6 months total).

Question 38

What factors determine whether to continue anticoagulation after 3 months?

Answer 38

The decision is based on balancing the patient’s risk of VTE recurrence and their risk of bleeding.

Question 39

What score can be used to assess the risk of bleeding?

Answer 39

The ORBIT score can be used to help assess the risk of bleeding.

Question 40

What does NICE state regarding unprovoked DVT or PE with low bleeding risk?

Answer 40

NICE states that the benefits of continuing anticoagulation treatment are likely to outweigh the risks in the absence of bleeding risk factors.

Question 41

What is the first-line treatment for massive PE with circulatory failure?

Answer 41

Thrombolysis is now recommended as the first-line treatment for massive PE where there is circulatory failure.

Question 42

What should be considered for patients with repeat pulmonary embolisms despite adequate anticoagulation?

Answer 42

Patients may be considered for inferior vena cava (IVC) filters, which prevent clots from moving to the pulmonary arteries.