Acute GP service
Cornwall
This is a site intended for clinicians - all guidelines must be interpreted in the context of clinical risk assessment
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
For more on interpreting PE likelihood click here
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.
PES1 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.
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
Post PE Diagnosis
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]
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
More on risk assessment post PE diagnosis:
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.
However it has a high Negative Predictive Value, i.e normal TnI is a strong indicator of Low Risk PE.
In a multicentre study involving 526 normotensive patients with acute PE, high sensitivity troponin exhibited a high NPV (98%)
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.
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
Predictive Value of hsTnT assay and the simplified Pulmonary Embolism Severity Index
Circulation 2011 Dec 13; 124(24):2716-24
Suspected PE assesment in the Acute GP clinic/Ambulatory Emergency Care Unit
