Incorporating: Acute GP, SDEC, UTC
Acute GP PE Protocol
PE Management top tips here
Two-level Wells PE score
Clinical probability simplified score
>4 points=PE likely
≤4 points=PE unlikely
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For more on interpreting PE likelihood click here
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Risk Stratifying the PE patient
Patient Normotensive/Haemodynamically stable? If so, the patient may be able to attend the Acute GP service for diagnosis and management.
Subsequent risk stratification relies on a number of clinical parameters to identify those normotensive patients who may have a risk of adverse outcome.
Pulmonary Embolism Severity Index (PESI) Score
This is an extensively validated prognostic tool, allowing the clinican to measure clinical severity and includes co-morbidity. It helps define low risk PE.
It’s major strength is that it has a high Negative Predictive Value, i.e. a low risk of I or II on PESI means that an adverse outcome is very unlikely.
Q scan trial - from January 2018
For an ongoing trial period, RCH Radiology will be trialling using Q scans rather than CTPA to diagnose PE in those people under the age of 40 without respiratory disease and all pregnant women. These patients must have a normal CXR and PEFR (within 100L/min for men or 85l/min for women of expected value for age and height) on the day of the Q scan.
Those who are not suitable for a Q scan (including asthmatics on active treatment (inc all inhalers), those with lungs signs or an abnormal CXR or PEFR less than expected) are to be discussed with radiology for a CTPA.
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The local RCHT pathway for anti-coagulation prescribing following diagnosis of PE:
1. refer to DVT clinic in clinic hours.
2. Outside DVT clinic availability or if AGP particularly wishes to prescribe:
• Discuss options and explain options
• Agree most suitable management
• Issue patient leaflet and patient alert card
• Issue an FP10 with the starting dose of DOAC in full i.e. 21 days of Rivaroxaban or 7 days of Apixaban
• Ensure that the FP10 is endorsed with a date to change dosage e.g. start on 1st march and continue until 22nd.
• Ensure that the patient is aware that a dose change is needed and when that change needs to be made
• Advise the patient that he/she must see GP before the starting dose change so that the next FP10 can be issued.
• Ensure that all this information is included on the patient discharge to own GP.
• This information is all contained in the RCHT website for anticoagulant guidelines and of course in the BNF.
• If pre-existing antiplatelets, the BMJ has summarised advice on co-prescribing anticoagulation here
For further acute anticoagulation advice, click here
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Post PE Diagnosis
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Once the diagnosis is established and a treatment plan has been agreed, the next decision is whether this is a Provoked or Unprovoked episode.
If the PE is unprovoked, then the Acute GP needs to
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Discuss this with the patient
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Carry out a full system review
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Ensure that the patient sees the referring GP for discussion on further investigation for possible underlying cancer.
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Advise the GP that occult cancer diagnosis needs to be considered.
Dr Andy Boorne has kindly summarised the below for unprovoked PE follow-up:
NICE Investigations for cancer
Prevalence of occult cancer after first unprovoke VTE is ~4-10%
Offer all patients diagnosed with unprovoked DVT or PE who are not already known to have cancer the following investigations for cancer:
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a physical examination (guided by the patient's full history) and
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a chest X-ray and
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blood tests (full blood count, serum calcium and liver function tests) and
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urinalysis. [2012] 1.5.2
Consider further investigations for cancer with an:
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abdomino-pelvic CT scan
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(and a mammogram for women)
...in all patients aged over 40 years with a first unprovoked DVT or PE who do not have signs or symptoms of cancer based on initial investigation (see recommendation 1.5.1). [2012]
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BMJ review April 2017 - felt the harm/benefit balance may mean patients may reject this further investigation. (CT TAP radiation dose equivalent to 234 CXRs, and a not insignificant false positive & incidential findings). They also recommend - safetynet, advise patient engage with normal cancer screening programmes and offer follow up appointment to review
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GP follow-up post PE:
Please can the Acute GP request follow-up by the patient's own GP within one week to ensure therapeutic compliance and the absence of complications, in keeping with BTS guidelines (Page ii18 BTS Guideline for the initial outpatient management of pulmonary embolism).
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More on risk assessment post PE diagnosis:
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CT assessment of RV dysfunction
The prognostic value of an enlarged r ventricle on CT was recently confirmed by an international prospective cohort study.
Findings are correlated with PE prognosis.
Cardiac Troponin
Elevated Cardiac TnI has been found in up to 50% of patients with PE.
It is unclear as to whether raised TnI alone is an indicator of adverse outcome.
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However it has a high Negative Predictive Value, i.e normal TnI is a strong indicator of Low Risk PE.
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In a multicentre study involving 526 normotensive patients with acute PE, high sensitivity troponin exhibited a high NPV (98%)
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BNP
BNP levels have been proposed as a tool for Risk Stratification.
Meta-analysis has shown that 51% of patients with PE have raised BNP and that this finding is associated with an adverse outcome, however the Positive Predictive Value (PPV) has been consistently low.
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References:
Pulmonary Embolism Risk Assessment and management
Eur Heart Journal 2012:33 (24) : 3014-3022
Pulmonary Severity Index and Troponin Testing
J. Thromb Haemostat 2010 Mar; 8(3) :517-22
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Predictive Value of hsTnT assay and the simplified Pulmonary Embolism Severity Index
Circulation 2011 Dec 13; 124(24):2716-24
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Suspected PE assesment in the Acute GP clinic/Ambulatory Emergency Care Unit
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