PE: STABLE: NOT PREGNANT

• Haemodynamically stable PE with a systolic BP ≥90 mmHg
• PE range from small with normal BP to large with borderline BP and right ventricular dysfunction
• If patient becomes haemodynamically unstable during management, follow PE: Unstable guideline

• Pulmonary venous thromboembolism (PE) is often missed clinically, particularly in:
• severe cardiorespiratory disease
• elderly patients
• Suspect the diagnosis in any patient who does not respond to initial therapy, or in whose condition there has been an unexplained deterioration
• Most episodes follow popliteal or iliofemoral DVT

Symptoms

• Small emboli present with dyspnoea
• Moderate-sized emboli present with signs of infarction and pleuritic pain
• Dyspnoea (present in 90% of cases) – may be of sudden onset
• Pleuritic chest pain
• Haemoptysis
• Syncope

Signs

• Tachypnoea (>20 breaths/min)
• Fever
• Pleural rub
• Tachycardia
• Maybe absent

Differential diagnosis

• Pneumonia
• Myocardial infarction (MI)
• Exacerbations of asthma and COPD

• FBC, INR, APTT and U&E

ECG and CXR

• ECG and CXR are often normal
• not to be used to confirm/refute the diagnosis
• useful for identifying other diseases and explaining symptoms
• ECG may show:
• sinus tachycardia, an S1 Q3 T3 pattern
• right bundle branch block, P pulmonale or right axis deviation
• Chest X-ray may show:
• non-specific shadows or a raised hemidiaphragm
• pulmonary oligaemia, linear atelectasis or small pleural effusion

Ordering D-dimer, perfusion scan or CTPA?

• Order test indicated by two-level PE Wells score, clinical status and chest x-ray results

D-dimer

• Raised in many clinical states
• do not request if clinical probability of PE is high, in probable massive PE or where an alternative diagnosis is highly likely
• normal D-dimer concentration virtually rules out thrombosis

Leg Doppler ultrasound

• Alternative to lung imaging in patients with clinical DVT 

• Follow selectors below or flowchart (equivalent)
• Choose result of test indicated by two-level PE Wells score, clinical status and chest x-ray results

General

• Oxygen – see Treatment of hypoxaemia guideline
• Adequate analgesia for pleuritic pain – paracetamol alone is unlikely to be adequate
• if well hydrated and eGFR ≥30 mL/min, ibuprofen 400 mg oral 8-hrly
• in dehydrated patient or if eGFR <30 mL/min, to prevent renal damage, prefer morphine sulphate 10 mg oral 4-hrly – ibuprofen may be substituted once adequate fluid replacement achieved if eGFR ≥30 mL/min
• if patient pregnant, prefer morphine sulphate 10 mg oral 4-hrly
• if patient taking ACE inhibitor avoid NSAIDS, including ibuprofen
• A high right atrial pressure (i.e. ↑JVP) is common and does not need to be treated
• AVOID diuretics

Specific

• Commence dalteparin as soon as PE suspected – see Dalteparin for VTE guideline
• if anticoagulation contraindicated, consultant physician, staff physician must decide which carries most risk – complications of therapy (consider a vena caval filter) or the DVT

Inferior vena caval filter (IVCF)

• Temporary IVCF can be used if patient:
• cannot have anticoagulation treatment, which will need to be removed when patient becomes eligible for anticoagulation therapy
• recurrent VTE despite increasing INR target range to 3–4 or trial of Dalteparin – discuss with haematology
• ensure strategy for removing IVCF at earliest possible opportunity is planned and documented

Assess suitability for ambulatory care

• Assess patients by sPESI risk score and exclusion criteria

Check exclusion criteria

Decision

• If sPESI is high risk or an exclusion criterion, manage as inpatient
• consider for early discharge when low risk score
• If SPESI is low risk and no exclusion criterion, manage as ambulatory care

Suitable for ambulatory care of PE

• Refer to AMU or ambulatory emergency care centre (AEC)
• Provide patient information on:
• signs and symptoms of recurrence, major bleeding and additional complications
• AMU and AEC contact details in event of complications and concerns
• Complete the PE Ambulatory proforma
• Arrange review in AEC within a week of discharge
• Refer to respiratory clinic

• Daily clinical examination for signs of further embolism, right heart failure, and secondary infection of a pulmonary infarct 

Monitoring dalteparin treatment

• See Dalteparin for VTE guideline

Inferior vena caval filter (IVCF)

• Temporary IVCF can be used if patient:
• cannot have anticoagulation treatment, which will need to be removed when patient becomes eligible for anticoagulation therapy
• recurrent VTE despite increasing INR target range to 3–4 or trial of dalteparin – discuss with haematology
• ensure strategy for removing IVCF at earliest possible opportunity is planned and documented

Maintenance anticoagulation

• Start warfarin as soon as diagnosis confirmed – see Warfarin guidelines
• Continue Dalteparin (see Dalteparin for VTE guideline) for a minimum of 5 days until:
• INR established within therapeutic range 2–3 (3–4 for recurrent DVT occurring while INR within the range 2–3) for at least 2 consecutive days
• If patient injection drug user or has active cancer, consider continuing therapeutic dalteparin treatment, rather than converting to warfarin
• If APTT ratio exceeds 2.5 in a patient being given unfractionated heparin
• INR may be elevated by heparin
• do not use INR as a guide to adjustment of warfarin dosage

Rivaroxaban

• If LMWH or warfarin not suitable, consider rivaroxaban, particularly if:
• previous intracranial bleed
• ≥12 months anticoagulant therapy is required
• anticipated difficulties with INR monitoring and understanding dose adjustments
• needle phobia
• other comorbidities (e.g. deranged LFT, excessive alcohol intake) increasing risk of bleeding on warfarin. Discuss with haematologist
• Contraindicated if eGFR <15 mL/min, in pregnancy and if breastfeeding

Dosage and monitoring

• 15 mg 12-hrly oral for first 3 weeks, 20 mg daily oral thereafter for duration of therapy
• No monitoring is required
• If 15mL/min < eGFR <50 mL/min, reduce dose as per BNF – discuss with haematologist

Screen for cancer

• In all patients with a confirmed PE, Chest X-ray, FBC, LFT, calcium and urinalysis
• If patient aged >40 yr has first unprovoked PE, consider performing:
• a thoraco-abdominal–pelvic or abdominal-pelvic (discuss with radiology) CT scan
• for women, a mammogram

Screen for thrombophilia

• If patient aged <45 yr with unprovoked PE, discuss screening for inherited or acquired thrombophilia with haematology consultant

• Ensure INR in appropriate range and stable

Duration of anticoagulation

• After a first provoked thromboembolic event, continue warfarin for 3 months
• Continue indefinitely for life-threatening PE
• For recurrent or unprovoked PE discuss with haematology and/or respiratory physician
• If patient has active cancer, reassess risks and benefits of continuing anticoagulation at 6 months

Outpatient investigations

• If evidence of right ventricular dysfunction or raised Troponin or BNP biomarkers, arrange echocardiogram
• arrange follow-up for result in 10-12 weeks for respiratory clinic

Advice to patient

• Advise patient that many drugs (including alcohol) interact with warfarin
• To remind their GP, if additional medication is prescribed, that they are taking warfarin
• Give patient a yellow anticoagulation therapy record booklet in which the following information has been entered:
• indication for warfarin, target INR
• start date and duration of therapy
• the last 4 INR results and date of next INR

Monitoring

• Refer to anticoagulant management service for follow-up appointment date
• Ensure discharge letter includes diagnosis, dosage of warfarin and date of clinic appointment
• If anticoagulation to be monitored by GP, supply GP with written information (on separate sheet, stapled to discharge letter) about:
• indication for anticoagulation
• proposed duration of treatment
• proposed target range for INR
• details of anticoagulation in hospital (give dates, INR results and dosage taken)

Document

• Document in medical record
• patient has been given written and verbal information about warfarin and has been referred to anticoagulation clinic
• duration of treatment
• outpatient investigations
• monitoring arrangements