Pulmonary embolism

Question 1

Strong risk factors

Answer 1

Lower limb # or hip or knee replacement- remain high up to three months with replacement
Major trauma
MI within prev 3 months
prev VTE
Spinal cord injury
hospitalisation for heart failure or AF within three months

Note that stroke, post partum, HRT, CCF or resp failure, CVC all moderate only
Note that prolonged travel, age, pregnancy pretty weak

Question 2

What is the increase risk with pregnancy?

Answer 2

T3 to 6 weeks PP–>up to 60 x increased risk

Question 3

After 12 months, risk of a recurrence of VTE after stop anticoagulation?

Answer 3

10%

Question 4

What is the difference between Geneva and Wells scores?

Answer 4

No reliance on clinical judgement (ie other diagnoses more likely etc) with Geneva score. Both used to assess PRETEST PROBABILITY OF VTE

Question 5

Which test excluded PE if there is a high pre-test probability?

Answer 5

V/Q (but problem is that 50% of the scans are non diagnostic)

Perfusion scan alone is enough in people with normal CXR

Question 6

What should you do when there is discrepancy between clinical probability and CT results?

Answer 6

Further testing

Also be aware that on the other hand CTPA overdiagnoses VTE

Question 7

Do you need to treat subsegmental PE?

Answer 7

No

Question 8

When would you do an echo?

Answer 8

IN high risk PE patients ti identify patients with RV dysfunction (shock or hypotension)
Higher mortality and morbidity from their PEs

Question 9

is BNP useful here?

Answer 9

BNP under 50 predicted an uncomplicated course in 95%–>use to identify candidates for home care

Question 10

PE severity index good for…

Answer 10

Identifying low risk patients

Question 11

When do you prefer to use UFH in acute PE?

Answer 11

Renal failure
Obesity
Patient having thrombolysis

Overall better with LMW heparin: lower mortality, recurrence, thromboembolic events, major bleeding

Question 12

What agent to use in active cancer precipitating PE

Answer 12

Consider indefinite treatment with LMWH over warfarin.
20% higher recurrence risk
Treat for at least 3-6 months

Question 13

Who is considered for indefinite treatment after first PE?

Answer 13

Recurrent VTE
Antiphospholipid ab syndrome
Homzygotes for a hereditary thrombophilia
Residual thrombus in proximal veins
Persistent RV dysfunctionon echo

Question 14

If you are very high bleeding risk, does aspirin help?

Answer 14

30-35% risk reduction
less than half as good as anticoagulation
Low rates of bleeding

Question 15

What is the advantage for NOACs in VTE treatment?

Answer 15

Lower risk of major bleeding.

Lower risk of ICH but higher risk of GI bleeding in AF trials

Question 16

If thrombolysis has failed, what do you try?

Answer 16

Surgical pulmonary embolectomy (or less good evidence but percutaneous catheter directed treatemtn)

Question 17

What are the risks of an IVC filter?

Answer 17

Reduced short term PE mortality
Increased risk of recurrent VTE
Post thrombotic syndrome in 40%
Occlusion of IVC 33% at 9 years