clinical knowledge summaries cks pulmonary embolism (pe) diagnosis and management in primary care....

Clinical Knowledge Summaries

CKS Pulmonary embolism (PE)

Diagnosis and management in primary care.

Educational slides based on the CKS topic Pulmonary embolism (June 2013), and NICE guidance (2012a): Venous thromboembolic disease: the management of venous thromboembolic diseases and the role of thrombophilia testing.

Key learning points and objectives• To be able to

o Recognise people who are considered to be at high risk of PE and need immediate admission.

o Assess the likelihood of a of a PE using the two-level PE Wells score.

o Describe when it is appropriate to give a parenteral anticoagulant and which one should be offered.

o Outline what management and follow up is required after discharge from hospital.

PE – background information• A PE is where one or more emboli are lodged

in and obstruct the pulmonary arterial system.

• The annual incidence of PE is around 3–4 per 10,000 people.

• A PE may be:o Provoked – associated with a transient risk factor

(e.g. significant immobility, surgery).o Unprovoked – no identifiable risk factor or a risk

factor that is persistent and not easily correctable (e.g. active cancer).

Based on the CKS topic Pulmonary embolism (June 2013), and NICE guidance (2012a): Venous thromboembolic disease: the management of venous thromboembolic diseases and the role of thrombophilia testing.

Sources of emboli• The most common source is deep vein thrombosis

(DVT) in the lower limbs (80%).• Other sources include:

o Emboli originating in the abdominal or axillary veins, or from the right ventricle.

o Tumours – mostly prostate and breast cancer. o Fat from long bone fractures.o Amniotic fluid – pregnant women. o Sepsis – e.g. infected indwelling catheters.o Foreign bodies (e.g. during IV drug use).o Air – admitted during surgery.


Major risk factors for PE• Major risk factors include:

o Deep vein thrombosis (DVT).o Previous DVT or pulmonary embolism.o Active cancer.o Recent surgery, hospitalization, lower limb

trauma, or other immobilization (including long-distance sedentary travel).

o Pregnancy, in particular 6 weeks postpartum.


Other risk factors• Other risk factors include:

o Increasing age (older than 60 years of age).o Combined oral contraception and hormone replacement

therapy.o Obesity (body mass index greater than 30 kg/m2).o One or more significant medical comorbidities (e.g. heart

disease, acute infectious disease, inflammatory conditions).

o Varicose veins.o Superficial venous thrombosis.o Known thrombophilias.


What else might it be?• Other conditions that could mimic the

symptoms of a PE include:o Respiratory conditions (e.g. pneumothorax).o Cardiac conditions (e.g. acute coronary

syndrome).oMusculoskeletal chest pain.o Gastro-oesophageal reflux disease.o Pregnancy.o Any cause for collapse such as vasovagal syncope.


Complications• Mortality

o Untreated, the risk of death from a PE is high (23–87%). o When treated with heparin and anticoagulants the risk of

death ranges from 2-6%.o For a clinically massive PE the risk of death is about 50%.o PE is the leading cause of maternal deaths in the UK.

• Chronic thromboembolic pulmonary hypertension (CTEPH) o Occurs in 0.5–5% of people with treated PE.


When to suspect a PE• Suspect a PE if the person has:

o Dyspnoea, tachypnoea, pleuritic chest pain, or features of a DVT.o These features are present in 97% of people with PE,

butoOnly 15% of people with a PE have signs of DVT.

o Other features such as tachycardia, haemoptysis, syncope, hypotension (systolic BP less than 90 mmHg), crepitations, cough or fever.

o A risk factor for PE (e.g. previous DVT/PE, pregnant).


When to suspect a PE• To exclude an alternative cause:

o Carry out a physical examination.o Review the person's general medical history.

• ECG or chest X-rayo Are of limited value as they are usually normal in

someone with a PE.oMay be done as part of investigations for

breathlessness or chest pain when another diagnosis seems more likely.


Managing a suspected PE• Arrange immediate admission if the person is:

o Pregnant or has given birth within the past 6 weeks.o It is not possible to accurately assess the risk of PE in primary care.

o Severely ill with: • Altered level of consciousness.• Systolic BP of less than 90 mm Hg.• Heart rate of more than 130 beats per minute.• Respiratory rate of more than 25 breaths per minute.• Oxygen saturation of less than 91%.• Temperature of less than 35°C.


Managing a suspected PE

• For all other people use the two-level PE Wells score to assess likelihood of PE and inform further management.

• Using this score a PE is:o Likely if the score is more than 4 points.

o Unlikely if the score is 4 points or less.


Using the two level PE Wells score• Scoring is as follows:

o Score 3 points if:• There are clinical features of a DVT.• An alternative diagnosis is less likely than a PE.

o Score 1.5 points if: • Heart rate is greater than 100 beats per minute.• Immobilization for more than 3 days.• Surgery in the previous 4 weeks.• Previous DVT or PE.

o Score 1 point if the person has:• Haemoptysis.• Cancer.


If PE likely (>4 points)• Arrange immediate admission for a computed

tomography pulmonary angiogram (CTPA), or• If there will be a delay in the person receiving a

CTPA:o Give immediate interim low molecular weight heparin

(LMWH) or fondaparinux, and o Arrange hospital admission.

• Body weight is required to prescribe LMWH or fondaparinux.


If PE unlikely (4 points or less)• Arrange a D-dimer test.• If the D-dimer test is positive:

o Arrange admission to hospital for an immediate CTPA, or

o If a CTPA cannot be carried out immediately, give LMWH or fondaparinux and arrange hospital admission.

• If the D-dimer test is negative, consider an alternative diagnosis.


Which parenteral anticoagulant?• Offer a choice of low molecular weight

heparin (LMWH) or fondaparinux. o Licensed LMWHs for DVT treatment include

dalteparin, enoxaparin, and tinzaparin.o Fondaparinux is a synthetic pentasaccharide that

inhibits activated factor X.• Choice of parenteral anticoagulant depends

on:o Comorbidities, contraindications, and cost.

• Local policy may also influence choice.Based on the CKS topic Pulmonary embolism (June 2013), and NICE guidance (2012a): Venous thromboembolic disease: the management of venous thromboembolic diseases and the role of thrombophilia testing.

Treatments in secondary care• Once a PE has been confirmed in secondary

care, most people will be initiated on long term treatment with either:o An oral anticoagulant (warfarin or rivaroxaban), or o A LMWH.

• LMWH are usually indicated if oral anticoagulants are:o Contraindicated, for example pregnancy, or o Less preferred, for example cancer

• Thrombolytic therapy or embolectomy may be offered to people who are not haemodynamically stable.


Duration of treatment• Specialists will usually decide on the duration of

treatment, however in general:o Treatment is usually continued for 3 months in people with

a provoked PE.o Treatment is continued for more than 3 months in people with

an unprovoked PE.• For pregnant women

o LMWH is continued until the end of pregnancy (unlicensed use).• For people with active cancer

o LMWH is continued until the cancer is considered cured or for at least 6 months.

o Dalteparin licensed for long term use in people with solid tumours.


What is the risk of recurrence?

• Risk of recurrence depends on individual risk factors, but in general:o Recurrence is lower for people with a provoked PE

(compared with unprovoked).o Without treatment - the risk of recurrence is

approximately 50%. o With treatment (3 months of anticoagulation) -

the risk of recurrence is around 8%.


Follow up for PE• For people with an unprovoked PE:

o Investigate for the possibility of an undiagnosed cancer if they are not already known to have cancer.

o Apparent unprovoked venous thromboembolism is associated with a significant increase in the risk of cancer (11%) within the first 1-2 years.

o Consider antiphospholipid testing before stopping anticoagulants.

o Consider arranging hereditary thrombophilia testing if there is a first-degree relative who has had a DVT or PE.


Follow up for PE

• Ensure adequate regular monitoring for warfarin or rivaroxaban.oMonitoring requirements for warfarin

and rivaroxaban differ.


Monitoring warfarin• Monitor the international normalized ratio (INR)

and adjust the dose as required. • The target INR for people with a PE is between 2

and 3 (ideally 2.5). • Usually monitor INR:

o Initially - daily, or every other day, until within therapeutic range, then

o Twice weekly for 1–2 weeks, theno Weekly until at least two INR measurements are within

range, thereaftero Depends on the stability of the INR but usually longer

intervals (e.g. up to every 12 weeks).Based on the CKS topic Anticoagulation – 0ral (May 2013)

Monitoring rivaroxaban• No need to monitor the INR, however

o Regular follow up and monitoring is still required.• Follow up every 3 months to assess for:

o Compliance and adverse effects (e.g. bleeding).• Repeat renal and liver function tests as well as the

full blood count at least once a year.• Repeat renal function tests:

o Every six months if the person has a creatinine clearance (CrCl) of 30–60 mL/min.

o Every three months if the person has a CrCl of 15–30 mL/min.

• If renal function has declined, review treatmento Rivaroxaban may need to be stopped or the dose lowered.

Based on the CKS topic Anticoagulation – 0ral (May 2013)

Summary• The most common source of PE is a DVT in the lower limbs (80%).• Untreated, the risk of death from a PE is high (23–87%). • When treated with heparin and anticoagulants the risk of death ranges from 2-

6%.• Arrange immediate admission if the person is:

o Pregnant or has given birth within the past 6 weeks.o Severely ill with, for example altered level of consciousness.

• For every one else use the two-level PE Wells score to assess likelihood of PE. A PE is:o Likely if the score is more than 4 points. o Unlikely if the score is 4 points or less.

• If PE is likely - arrange immediate admission for a CTPA, or if there will be a delay in the person receiving a CTPA:

o Give immediate interim low molecular weight heparin (LMWH) or fondaparinux, and arrange hospital admission.

• If PE is unlikely - arrange a D-dimer test, if the D-dimer test is positive:o Arrange admission to hospital for an immediate CTPA, oro If a CTPA cannot be carried out immediately, give LMWH or fondaparinux and arrange hospital

admission.

clinical knowledge summaries cks pulmonary embolism (pe) diagnosis and management in primary care....

Documents

o emboli

o pregnancy

o sepsis

o tumours

o unprovoked

o active cancer

o previous dvt

o recent surgery