Pulmonary Embolism History-Taking | Resp History - MedSchool
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Pulmonary Embolism History-Taking

 
 
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Overview

    • Ask About

    • Diagnosis - provoked or unprovoked PE, preceding DVT
    • Management - anticoagulation
    • Complications - infarction, right heart failure, pulmonary hypertension
    • Risk Factors for Pulmonary Embolism

    • Genetic Predisposition

    • Inherited hypercoagulability - protein C or S deficiency, factor V Leiden, prothrombin gene mutation, sickle cell disease, hyperhomocysteinaemia, antithrombin III deficiency
    • Family history of VTE
    • Patient  Factors

    • Advanced age
    • Past history of VTE
    • Acquired hypercoagulability - antiphospholipid syndrome, hyperviscosity, PNH, TTP, HITS
    • May-Thurner syndrome (anatomical variant where the right common iliac artery overlies and compresses the left common iliac vein)
    • Malignancy
    • Hormonal therapy - oestrogen-containing oral contraceptives, hormone replacement, SERMs
    • Venous pathology - varicose veins, superficial vein thrombosis
    • Environmental Triggers

    • Trauma
    • Surgery - particularly hip / knee surgery or major surgery
    • Pregnancy / peripartum period
    • Continuous immobilisation >72 hours - bedrest, neurologic pathology, cast
    • Hospital or nursing home admission
    • Long-distance travel (air, land or sea)

Complications

    • Complications of Pulmonary Embolism

    • Disease-Related

    • Pulmonary infarction
    • Right heart failure
    • Chronic thromboembolic pulmonary hypertension (CTEPH)
    • Treatment-Related

    • Major bleeding

Management

    • Management Options

    • Thrombolysis (haemodynamically unstable patients)
    • Anticoagulation - heparin, low molecular weight heparin, warfarin, dabigatran, rivaroxaban, apixaban
    • Pearls: Choice of Anticoagulant

    • Heparin infusion - short-term, for bridging or in the perioperative period. APTT must be monitored regularly as per local protocol.
    • Low molecular weight heparin (e.g. enoxaparin) - first line for patients with active malignancy; also used for bridging. Contraindicated if CrCl <30.
    • Warfarin - must be bridged. INR must be monitored. Can be used in renal failure. Inferior to enoxaparin in active malignancy.
    • Dabigatran - contraindicated if CrCl <30.
    • Rivaroxaban - contraindicated if CrCl <30, severe liver disease, on protease inhibitors / azoles, pregnancy / breastfeeding. Potential role in active malignancy.
    • Apixaban - contraindicated if CrCl <25, severe liver disease, on protease inhibitors / azoles, pregnancy / breastfeeding.
    • Contraindications to Anticoagulation

    • Absolute - active bleeding, major trauma, platelets <50, bleeding diathesis, perioperative
    • Relative - past incompressible bleed, intracranial or spinal tumour, platelets <100, large AAA, high falls risk
    • Duration of Anticoagulation

    • Provoked VTE (transient risk factors) - 3 months then reassess based on risk of recurrence and bleeding
    • First unprovoked VTE - 3 months then continue depending on risk of recurrence and bleeding
    • Recurrent unprovoked VTE - long-term anticoagulation
    • Thrombophilia - consider long-term anticoagulation
Last updated on May 1st, 2019
 
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