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Pulmonary Embolism

The document presents a case study of a 57-year-old woman, Ms. S, who was diagnosed with an intermediate-risk pulmonary embolism (PE) after presenting with chest pain and dyspnea. She was treated with anticoagulation therapy and advised to continue with Apixaban for six months, with follow-up and monitoring for potential recurrence. Guidelines for managing PE emphasize the importance of risk stratification and the need for indefinite antithrombotic therapy for unprovoked cases like Ms. S's.

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Hermon Wong
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18 views16 pages

Pulmonary Embolism

The document presents a case study of a 57-year-old woman, Ms. S, who was diagnosed with an intermediate-risk pulmonary embolism (PE) after presenting with chest pain and dyspnea. She was treated with anticoagulation therapy and advised to continue with Apixaban for six months, with follow-up and monitoring for potential recurrence. Guidelines for managing PE emphasize the importance of risk stratification and the need for indefinite antithrombotic therapy for unprovoked cases like Ms. S's.

Uploaded by

Hermon Wong
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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The Great Masquerader:

Pulmonary Embolism
DR HERMON WONG
Ms. S

 57-year-old woman
 Non-smoker, no history of OCP use, no comorbidities
 Presented to ED with 3 day history of exertional chest pain and
dyspnea – tried taking OTC painkiller (no resolve)
 Her vitals was normal including her SPO2 100% on room air
 She was tachycardic but otherwise comfortable
Ms. S

 D-dimer was greater than 50,000µg/L (reference range, <500 µg/L)


and troponin was 0.08 μg/L (reference range, 0 to 0.01 μg/L)
 EKG showed sinus tachycardia with right axis deviation
 CT angiogram showed near-occlusive PE in the right main
pulmonary artery extending into branch arteries, emboli in the left
lower pulmonary artery, and bowing of the interventricular septum
 Bedside echocardiogram revealed right heart strain
Pulmonary Embolism

 Venous Thromboembolism (VTE) = PE and/or DVT


 PE increases mortality risk in the short and long term
 30-year nationwide population-based cohort study in Denmark showed first-
time VTE patient had the most pronounced difference in mortality risk
than the comparison cohort within the first-year of follow-up;
 Patients surviving >1 year, MRR remains elevated but the difference reduced
 PE can be stratified into low, intermediate and high risk
 Hemodynamic status
 RV dysfunction or elevated biomarkers
Ms S

 Echocardiogram showed RV strain


 Troponin is elevated
 She is hemodynamically stable
 Intermediate risk PE
 She was admitted to the medical ward for close monitoring and
treatment
 She was given SC Enoxaparin BD for the first few days
 Over the next few days, her chest pain and dyspnea resolved
 Subsequently transitioned to Apixaban
Where to treat PE?

 Low-risk PE can be managed in the outpatient setting


 Intermediate- and high-risk PE are managed in the inpatient setting
 Close monitoring
 Access to advanced therapies
 Intravenous systemic thrombolysis
 Surgical embolectomy
 Catheter-based therapies such as catheter-directed thrombolysis and catheter-
directed embolectomy.
Guidelines

 American Society of Hematology 2020 Guidelines for Management of


Venous Thromboembolism: Treatment of Deep Vein Thrombosis and
Pulmonary Embolism
 Uncomplicated DVT and PE with low risk for complications: Suggests
home treatment over hospital treatment
 Suggests using DOAC over VKAs (may not apply to those with renal
insufficiency, moderate to severe liver disease, or antiphospholipid
syndrome)
 PE with hemodynamic compromise: Recommends using thrombolytic
therapy followed by anticoagulation over anticoagulation alone
 PE with echocardiography and/or biomarkers compatible with RVD
but without hemodynamic compromise: suggests anticoagulation alone
Risk Factors

 Can be classified
 Provoked vs Unprovoked – most important
recurrence stratification tool
 Major or minor and transient vs Chronic
 To assess patient’s risk for subsequent VTE
after initial anticoagulation
 To inform decisions about the advisability or
duration of secondary-prevention
anticoagulation
 Ms S – unprovoked
Primary treatment & Secondary
Prevention
Secondary Prevention

 ASH guideline panel suggests against routine use of prognostic scores,


D-dimer testing, or ultrasound to detect residual vein thrombosis to
guide the duration of anticoagulation
 Provoked transient PE/DVT typically do not require antithrombotic
therapy after completion of primary treatment
 Provoked chronic PE/DVT and Unprovoked PE/DVT: suggest indefinite
antithrombotic therapy over stopping anticoagulation after completing
of primary treatment
 Ms S – unprovoked  indefinite antithrombotic therapy
“Taking a medication for the rest of
my life”

 Long term risk of symptomatic recurrent venous thromboembolism


after discontinuation of anticoagulant treatment for first
unprovoked venous thromboembolism event: systematic review
and meta-analysis
 Stopping anticoagulant therapy after 3-6 months of primary treatment, the
risk of recurrent VTE reached
 10% in the first year
 36% at 10 years
 with 4% of recurrent VTE events resulting in death
Ms. S

 We have advised her to continue with her Apixaban 6 months (primary


treatment)
 Monthly follow-up and blood works to be done
 CBC
 CMP
 D-dimer
 Thrombophilia testing to be arranged later
HERDOO2 Rule
References

 Søgaard KK;Schmidt M;Pedersen L;Horváth-Puhó E;Sørensen HT; (n.d.). 30-year mortality


after venous thromboembolism: A population-based Cohort Study. Circulation.
https://pubmed.ncbi.nlm.nih.gov/24970783/
 American Society of Hematology 2020 Guidelines for management of venous
thromboembolism: Treatment of deep vein thrombosis and pulmonary embolism | blood
advances | american Society of Hematology. (n.d.).
https://ashpublications.org/bloodadvances/article/4/19/4693/463998/American-Society-of-
Hematology-2020-Guidelines-for
 Khan, F., Rahman, A., Carrier, M., Kearon, C., Weitz, J. I., Schulman, S., Couturaud, F.,
Eichinger, S., Kyrle, P. A., Becattini, C., Agnelli, G., Brighton, T. A., Lensing, A. W. A., Prins,
M. H., Sabri, E., Hutton, B., Pinede, L., Cushman, M., Palareti, G., … Rodger, M. A. (2019,
July 24). Long term risk of symptomatic recurrent venous thromboembolism after
discontinuation of anticoagulant treatment for first unprovoked venous thromboembolism
event: Systematic review and meta-analysis. The BMJ.
https://www.bmj.com/content/366/bmj.l4363
Thank You

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