Royal Cornwall Hospital

Truro

Cornwall TR1 3LJ

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© 2023 by Acute GP Service, CPFT. 

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

  • Discuss this with the patient

  • Carry out a full system review

  • Ensure that the patient sees the referring GP for discussion on further investigation for possible underlying cancer.

  • 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:

  • a physical examination (guided by the patient's full history) and

  • a chest X-ray and

  • blood tests (full blood count, serum calcium and liver function tests) and

  • urinalysis. [2012] 1.5.2

Consider further investigations for cancer with an:

  • abdomino-pelvic CT scan

  • (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