Pulmonary embolism - Covered In Cardio Flashcards
What are potential features of pulmonary embolism?
Potential features include chest pain (typically pleuritic), dyspnoea, haemoptysis, tachycardia, and tachypnoea.
In respiratory examination, classically the chest will be clear, but findings may vary in clinical practice.
What percentage of patients present with the textbook triad of pleuritic chest pain, dyspnoea, and haemoptysis?
Only around 10% of patients present with the textbook triad.
What study looked at the frequency of symptoms in pulmonary embolism patients?
The PIOPED study conducted in 2007.
What is the relative frequency of tachypnea in pulmonary embolism patients?
Tachypnea (respiratory rate >16/min) occurs in 96% of patients.
What is the relative frequency of crackles in pulmonary embolism patients?
Crackles are found in 58% of patients.
What is the relative frequency of tachycardia in pulmonary embolism patients?
Tachycardia (heart rate >100/min) is present in 44% of patients.
What is the relative frequency of fever in pulmonary embolism patients?
Fever (temperature >37.8°C) occurs in 43% of patients.
What criteria does Well’s use for diagnosing pulmonary embolism?
Well’s criteria for diagnosing a PE use tachycardia rather than tachypnoea.
What is the textbook triad of pulmonary embolism?
Pleuritic chest pain, dyspnoea, and haemoptysis.
What percentage of patients present with the textbook triad of pulmonary embolism?
Around 10%.
What are common clinical signs of pulmonary embolism according to the PIOPED study?
Tachypnea (96%), Crackles (58%), Tachycardia (44%), Fever (43%).
What is the significance of tachycardia in the Well’s criteria for diagnosing PE?
Well’s criteria use tachycardia rather than tachypnoea.
What should be done for patients with symptoms suggestive of PE?
A history taken, examination performed, and a chest x-ray to exclude other pathology.
What is the purpose of the pulmonary embolism rule-out criteria (PERC)?
To rule out PE when there is a low pre-test probability (< 15%).
What does a negative PERC result indicate?
Reduces the probability of PE to < 2%.
What should be done if suspicion of PE is greater than low probability?
Move straight to the 2-level PE Wells score.
What are the points assigned in the 2-level PE Wells score for clinical signs of DVT?
3 points for clinical signs and symptoms of DVT.
What indicates a PE is ‘likely’ in the 2-level PE Wells score?
More than 4 points.
What should be arranged if a PE is ‘likely’?
An immediate computed tomography pulmonary angiogram (CTPA).
What is the recommendation for interim therapeutic anticoagulation if there is a delay in CTPA?
Use low-molecular-weight heparin.
What anticoagulant is recommended if the CTPA is positive?
A direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban.
What should be done if a PE is ‘unlikely’ (4 points or less)?
Arrange a D-dimer test.
What is the consensus view on initial lung-imaging modality for non-massive PE?
CTPA is the recommended initial lung-imaging modality.
What are the advantages of CTPA over V/Q scans?
Speed, easier to perform out-of-hours, reduced need for further imaging, and possibility of providing an alternative diagnosis.
What should be considered for patients > 50 years regarding D-dimer levels?
Age-adjusted D-dimer levels.
What classic ECG changes are seen in PE?
Large S wave in lead I, large Q wave in lead III, and inverted T wave in lead III - ‘S1Q3T3’.
What is the sensitivity and specificity of D-dimers?
Sensitivity = 95-98%, but poor specificity.
What are the key changes in NICE’s 2020 guidelines for VTE management?
The key changes include recommending the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, the use of DOACs in patients with active cancer, outpatient treatment in low-risk pulmonary embolism (PE) patients, and that routine cancer screening is no longer recommended following a VTE diagnosis.
What is the current approach for outpatient treatment in low-risk PE patients?
Patients with a new diagnosis of PE who are deemed low-risk are increasingly managed as outpatients, supported by NICE’s latest guidance.
What tool does NICE recommend for determining outpatient treatment suitability?
NICE recommends using a ‘validated risk stratification tool’ to determine the suitability of outpatient treatment.
Which score is supported by the 2018 British Society guidelines for assessing PE severity?
The Pulmonary Embolism Severity Index (PESI) score.
What are the key requirements for outpatient treatment in low-risk PE patients?
Key requirements include haemodynamic stability, lack of comorbidities, and support at home.
What is the cornerstone of VTE management?
The cornerstone of VTE management is anticoagulant therapy.
What significant change occurred in the 2020 guidelines regarding anticoagulant therapy?
The significant change was the increased use of DOACs as first-line treatment following the diagnosis of a PE.
What should be offered first-line following a diagnosis of a PE?
Apixaban or rivaroxaban (both DOACs) should be offered first-line.
What is the new recommendation for patients with active cancer regarding anticoagulants?
The new guidelines recommend using a DOAC unless contraindicated.
What is the recommended length of anticoagulation for all patients?
All patients should have anticoagulation for at least 3 months.
How is the continuation of anticoagulation determined after the initial 3 months?
Continuation is partly determined by whether the VTE was provoked or unprovoked.
What defines a provoked VTE?
A provoked VTE is due to an obvious precipitating event, such as immobilisation following major surgery.
What is the typical treatment duration for a provoked VTE?
The treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer).
What is the typical treatment duration for an unprovoked VTE?
Treatment is typically continued for up to 3 further months (i.e., 6 months in total).
What score can be used to assess the risk of bleeding?
The ORBIT score can be used to help assess the risk of bleeding.
What does NICE recommend for patients with unprovoked DVT or PE and a low bleeding risk?
NICE states that the benefits of continuing anticoagulation treatment are likely to outweigh the risks.
What is the first-line treatment for massive PE with circulatory failure?
Thrombolysis is now recommended as the first-line treatment for massive PE where there is circulatory failure.
What may be considered for patients who have repeat pulmonary embolisms despite adequate anticoagulation?
Inferior vena cava (IVC) filters may be considered.
