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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
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