Pulmonary embolism - Covered In Cardio

Question 1

What are potential features of pulmonary embolism?

Answer 1

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.

Question 2

What percentage of patients present with the textbook triad of pleuritic chest pain, dyspnoea, and haemoptysis?

Answer 2

Only around 10% of patients present with the textbook triad.

Question 3

What study looked at the frequency of symptoms in pulmonary embolism patients?

Answer 3

The PIOPED study conducted in 2007.

Question 4

What is the relative frequency of tachypnea in pulmonary embolism patients?

Answer 4

Tachypnea (respiratory rate >16/min) occurs in 96% of patients.

Question 5

What is the relative frequency of crackles in pulmonary embolism patients?

Answer 5

Crackles are found in 58% of patients.

Question 6

What is the relative frequency of tachycardia in pulmonary embolism patients?

Answer 6

Tachycardia (heart rate >100/min) is present in 44% of patients.

Question 7

What is the relative frequency of fever in pulmonary embolism patients?

Answer 7

Fever (temperature >37.8°C) occurs in 43% of patients.

Question 8

What criteria does Well’s use for diagnosing pulmonary embolism?

Answer 8

Well’s criteria for diagnosing a PE use tachycardia rather than tachypnoea.

Question 9

What is the textbook triad of pulmonary embolism?

Answer 9

Pleuritic chest pain, dyspnoea, and haemoptysis.

Question 10

What percentage of patients present with the textbook triad of pulmonary embolism?

Answer 10

Around 10%.

Question 11

What are common clinical signs of pulmonary embolism according to the PIOPED study?

Answer 11

Tachypnea (96%), Crackles (58%), Tachycardia (44%), Fever (43%).

Question 12

What is the significance of tachycardia in the Well’s criteria for diagnosing PE?

Answer 12

Well’s criteria use tachycardia rather than tachypnoea.

Question 13

What should be done for patients with symptoms suggestive of PE?

Answer 13

A history taken, examination performed, and a chest x-ray to exclude other pathology.

Question 14

What is the purpose of the pulmonary embolism rule-out criteria (PERC)?

Answer 14

To rule out PE when there is a low pre-test probability (< 15%).

Question 15

What does a negative PERC result indicate?

Answer 15

Reduces the probability of PE to < 2%.

Question 16

What should be done if suspicion of PE is greater than low probability?

Answer 16

Move straight to the 2-level PE Wells score.

Question 17

What are the points assigned in the 2-level PE Wells score for clinical signs of DVT?

Answer 17

3 points for clinical signs and symptoms of DVT.

Question 18

What indicates a PE is ‘likely’ in the 2-level PE Wells score?

Answer 18

More than 4 points.

Question 19

What should be arranged if a PE is ‘likely’?

Answer 19

An immediate computed tomography pulmonary angiogram (CTPA).

Question 20

What is the recommendation for interim therapeutic anticoagulation if there is a delay in CTPA?

Answer 20

Use low-molecular-weight heparin.

Question 21

What anticoagulant is recommended if the CTPA is positive?

Answer 21

A direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban.

Question 22

What should be done if a PE is ‘unlikely’ (4 points or less)?

Answer 22

Arrange a D-dimer test.

Question 23

What is the consensus view on initial lung-imaging modality for non-massive PE?

Answer 23

CTPA is the recommended initial lung-imaging modality.

Question 24

What are the advantages of CTPA over V/Q scans?

Answer 24

Speed, easier to perform out-of-hours, reduced need for further imaging, and possibility of providing an alternative diagnosis.

Question 25

What should be considered for patients > 50 years regarding D-dimer levels?

Answer 25

Age-adjusted D-dimer levels.

Question 26

What classic ECG changes are seen in PE?

Answer 26

Large S wave in lead I, large Q wave in lead III, and inverted T wave in lead III - 'S1Q3T3'.

Question 27

What is the sensitivity and specificity of D-dimers?

Answer 27

Sensitivity = 95-98%, but poor specificity.

Question 28

What are the key changes in NICE's 2020 guidelines for VTE management?

Answer 28

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.

Question 29

What is the current approach for outpatient treatment in low-risk PE patients?

Answer 29

Patients with a new diagnosis of PE who are deemed low-risk are increasingly managed as outpatients, supported by NICE's latest guidance.

Question 30

What tool does NICE recommend for determining outpatient treatment suitability?

Answer 30

NICE recommends using a 'validated risk stratification tool' to determine the suitability of outpatient treatment.

Question 31

Which score is supported by the 2018 British Society guidelines for assessing PE severity?

Answer 31

The Pulmonary Embolism Severity Index (PESI) score.

Question 32

What are the key requirements for outpatient treatment in low-risk PE patients?

Answer 32

Key requirements include haemodynamic stability, lack of comorbidities, and support at home.

Question 33

What is the cornerstone of VTE management?

Answer 33

The cornerstone of VTE management is anticoagulant therapy.

Question 34

What significant change occurred in the 2020 guidelines regarding anticoagulant therapy?

Answer 34

The significant change was the increased use of DOACs as first-line treatment following the diagnosis of a PE.

Question 35

What should be offered first-line following a diagnosis of a PE?

Answer 35

Apixaban or rivaroxaban (both DOACs) should be offered first-line.

Question 36

What is the new recommendation for patients with active cancer regarding anticoagulants?

Answer 36

The new guidelines recommend using a DOAC unless contraindicated.

Question 37

What is the recommended length of anticoagulation for all patients?

Answer 37

All patients should have anticoagulation for at least 3 months.

Question 38

How is the continuation of anticoagulation determined after the initial 3 months?

Answer 38

Continuation is partly determined by whether the VTE was provoked or unprovoked.

Question 39

What defines a provoked VTE?

Answer 39

A provoked VTE is due to an obvious precipitating event, such as immobilisation following major surgery.

Question 40

What is the typical treatment duration for a provoked VTE?

Answer 40

The treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer).

Question 41

What is the typical treatment duration for an unprovoked VTE?

Answer 41

Treatment is typically continued for up to 3 further months (i.e., 6 months in total).

Question 42

What score can be used to assess the risk of bleeding?

Answer 42

The ORBIT score can be used to help assess the risk of bleeding.

Question 43

What does NICE recommend for patients with unprovoked DVT or PE and a low bleeding risk?

Answer 43

NICE states that the benefits of continuing anticoagulation treatment are likely to outweigh the risks.

Question 44

What is the first-line treatment for massive PE with circulatory failure?

Answer 44

Thrombolysis is now recommended as the first-line treatment for massive PE where there is circulatory failure.

Question 45

What may be considered for patients who have repeat pulmonary embolisms despite adequate anticoagulation?

Answer 45

Inferior vena cava (IVC) filters may be considered.