Transcript How do you approach a patient you think may have a PE?

How do you approach a patient
you think may have a PE?
Case 1
• 42 yo female presents to ED with complaint of 3
weeks of congestion and several days of difficulty
catching her breath
• No significant PMH, meds, non-smoker, no recent
immobility or surgeries
• T 37.9, P 82, RR 20, room air sats 98%
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Sinus tenderness, boggy turbinates, red throat
Lungs clear and no respiratory distress
CXR clear
Spiral CT reveals left lower lobe sub-segmental defect
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How good is a CTA (-CTV) to
rule in or out a PE?
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PIOPED II – NEJM, 2006
• Prospective cohort study
• Consecutive inpatient and outpatients with
suspected acute pulmonary embolism
• Composite reference standard
– Clinical assessment, VQ scanning, CUS, if
necessary DSA
• CTA-CTV – stringent standards
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PIOPED II – NEJM, 2006
• No PE
– Normal DSA
– Normal VQ scan
– Low or very low prob VQ scan, low prob Wells,
normal CUS
– PLUS telephone interviews at 3 and 6 months
• PE
– High Prob VQ scan
– Abnormal DSA
– Abnormal CUS
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Wells Criteria
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Results
• CTA
– Sensitivity 83%
– Specificity 96%
– +LR 19.6, -LR .19
• CTA-CTV
– Sensitivity 90%
– Specificity 95%
– +LR 16.5, -LR .11
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Problems
• Exclusions and dropouts
– “inconclusive results”
• 6% for CTA
• 11% for CTV
– Of 1090 enrolled, 238 did not receive
reference diagnosis
• This represents best case scenario
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Discordant clinical and
radiologic findings
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Christopher study – JAMA
2006
• Prospective cohort study of a sequential
application of a clinical decision rule, DDimer testing, and CTA
• Consecutive patients – sudden onset
dyspnea, sudden deterioration of existing
dyspnea, or sudden pleuritic chest pain
– ED and wards
• A modified Wells assessment, An elisa
ddimer test, and Multirow detector CT
scan
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3 month follow up
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Modified Wells
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PE?
Wells - Unlikely
D-Dimer Negative
Wells - Likely
D-Dimer Positive
CT - Angiogram
Observe, no therapy *
Negative
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Positive
Treat
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Venous Thromboembolic Events (VTEs) During 3-Month Follow-up (n = 3138)*
Writing Group for the Christopher Study Investigators, JAMA 2006;295:172-179.
Copyright restrictions may apply.
Summary
• Safety with concordant findings
– Low PTP/normal D-Dimer/negative CTA
• Consider going further if discordant
findings
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Lower Extremity Ultrasound
• Annals of Internal Medicine 01/98
• Cohort study of consecutive patients
presenting to referral center with
suspected DVT
• All underwent CUS initially and if normal
again in 5-7 days
• All followed for 3 months
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Prevention
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Limitations of the literature
• DVT screening methods
– Venography – 20-40% nondiagnostic, clinical
relevance of small thrombi
– DUS – poor accuracy for calf veins, operator
dependent
• End points
– Mortality > fatal PE > PE > Symptomatic DVT >
Asymptomatic DVT
• Industry sponsorship
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Risk Factors
• Increasing age (>50)
• Malignancy – history, active, under therapy
• Medications
– OCPs, HRT, SERM, Erythropoiesis stimulating
compounds
• Medical condition
– IBD, Nephrotic syndrome, history of MI, atrial
fibrillation, ischemic stroke, diabetes mellitus,
obesity, CHF, paralysis, previous VTE,
varicosities
• Thrombophilia
– FVL, Prothrombin gene mutation, Protein C, S,
ATIII deficiencies
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Prevalence of DVT in
hospitalized patients *
Patient Group
DVT Prevalence (%)
Medical Patients
10-20
General Surgery
15-40
Stroke
20-50
Hip/Knee Arthroplasty, HFS
40-60
Critical Care
10-80
*Objective screening for asymptomatic DVT in patients not receiving
thromboprophylaxis
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Medical Patients
• Pharmacologic Thromboprophylaxis
(LMWH, LDUH, fondaparinux)
recommended for…
acutely ill hospitalized patients with CHF,
severe respiratory disease or confined to bed
PLUS
one or more additional risk factors such as
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Active cancer
Previous VTE
Sepsis
Acute neurologic disease
IBD
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Meta-analysis
• Annals of Internal Medicine, February,
2007
• Anticoagulant prophylaxis to prevent
symptomatic venous thromboembolism in
hospitalized medical patients
• “Individual randomized trials of anticoagulant
prophylaxis in medical patients have been
underpowered to show a reduction in PE and have
assessed treatment effects on asymptomatic,
venography-detected DVT, which is a less
compelling outcome.”
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Meta-analysis
• Well designed and described search
strategy
• Two independent reviewers
• Treatment efficacy outcomes
– All-cause mortality, fatal and non-fatal
symptomatic PE, symptomatic DVT
• On-treatment period
• Anticoagulant Regimens
– LDUH 5000IU bid/tid, Enoxaparin 40-60mg daily or
30mg bid, Nadroparin 4000/6000 IU daily,
Dalteparin 5000IU daily or Fondaparinux 2.5mg
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Meta-analysis: Identification of eligible studies
Dentali, F. et. al. Ann Intern Med 2007;146:278-288
Any pulmonary embolism during
anticoagulant prophylaxis
Dentali, F. et. al. Ann Intern Med 2007;146:278-288
Fatal pulmonary embolism during
anticoagulant prophylaxis
Dentali, F. et. al. Ann Intern Med 2007;146:278-288
All-cause mortality during
anticoagulant prophylaxis
Dentali, F. et. al. Ann Intern Med 2007;146:278-288
Symptomatic deep venous thrombosis during anticoagulant
prophylaxis
Dentali, F. et. al. Ann Intern Med 2007;146:278-288
Major bleeding during
anticoagulant prophylaxis
Dentali, F. et. al. Ann Intern Med 2007;146:278-288
Limitations
• Not all studies were double blind
– Diagnostic suspicion bias
• Best agent?
– No head to head comparisons in this study
• Lack of standardized definition for major
bleeding
• Pharmaceutical support
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Summary
• Those at highest risk receive greatest
benefit from an intervention
– Risk stratify surgical and medical
patients (Joint Commission Requirement)
– Provide anticoagulant prophylaxis to
moderate and high risk surgical patients
– Provide anticoagulant prophylaxis to
most** hospitalized medical patients
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