PE service Regional College Lecture PE Management Update in medicine (Eastern) Cambridge 29 th June 2017 Dr Rachel M Limbrey DM FRCP University Hospital Southampton NHS Foundation Trust Ambulatory acute service Who and how PE follow up service Who, why and how Team work ED, AMU, Respiratory, Haematology 65 years old lady What would you do next? 3/7 hx SOB No previous VTE / FH No significant co-morbidities CTPA confirmed PE What would you do next? Send home with oral anticoagulation Send home with oral anticoagulation and tell her for 6 months duration ECG / Troponin / spesi What would you do next? Risk stratification Send home with oral anticoagulation Send home with oral anticoagulation and tell her for 6 months duration ECG / Troponin / spesi Severity of PE assessed as an individuals estimate of PE related early (30 day) mortality risk rather than anatomical burden Low risk <1% Intermediate risk 3-15% High risk >15% Torbicki A et al. Eur Heart J 2008;29:2276-2315. 1
Simplified PESI score Ambulatory Service Age >80 years History of cancer History of chronic cardiopulmonary disease HR 110bpm Systolic BP <100mmHg O2 sats <90% Score 1 per criterion spesi 1 intermediate risk spesi =0 low risk New acute PE Managed by Acute Medical Unit Low risk of 30 day mortality PESI score (Pulmonary Embolism Severity Index) Jimenez D et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic embolism. Arch Intern Med 2010;170:1383-1389. Southampton PE FU model Patients assessed and diagnosed in ED/AMU Risk stratify then consider for ambulatory care Rivaroxaban first line anticoagulant Electronic referral system to PE Clinic AMU CNS phone call at 2-3 days FU by Pulmonary Vascular CNS at 3/52 Doctor FU in PE clinic at 3/12 65 years old lady 3/7 hx SOB No previous VTE / FH No significant co-morbidities CTPA confirmed PE What length anticoagulation would you advise? 2
What length anticoagulation? 3 months 6 months Long term Not sure What length anticoagulation? 3 months 6 months Long term Not sure Provoking Factors Approximately 50% PEs unprovoked or idiopathic Idiopathic PE associated with a 2-3 fold increased risk of recurrence and death Major provoking factors include active malignancy, surgery, trauma Minor provoking factors include OCP, HRT and travel related Incidence of VTE increases with age, markedly over age 75 years, 8 fold higher >80 years cf <50 years 65 years old lady 3/7 hx SOB No previous VTE / FH No significant co-morbidities CTPA confirmed PE What, if any, screening tests would you do? What, if any, screening tests would you do? None, the chance of picking up an undeclared malignancy is slim None, but educate about underlying malignancy and presenting early Staging CT (ie chest/abdo/pelvis) Targeted screening including PSA or mammogram, and USS abdo/pelvis 3
What, if any, screening tests would you do? None, the chance of picking up an undeclared malignancy is slim None, but educate about underlying malignancy and presenting early Staging CT (ie chest/abdo/pelvis) Targeted screening including PSA or mammogram, and USS abdo/pelvis Screening for occult malignancies Screen those with an unprovoked event Mammogram or PSA, USS abdo and pelvis, review bloods (HB, MCV etc) NICE guidance 2012, consider staging CT in those >40 years with first idiopathic event Thrombophilia Screening Heritable include FVL and Prothrombin gene mutations Heritable also include deficiencies of the natural anticoagulants Protein S, Protein C (can t measure on warfarin) and antithrombin III activity Antiphospholipid abs (anticardiolipin abs & lupus anticoagulant) are an acquired thrombophilia Who to screen? Debatable Be aware of limitations Anxiety and overestimated perception of risk Use for young unprovoked or those with very minor provoking factors eg travel, HRT, OCP Strong FH VTE Not necessary if continuing anticoagulation See BJH Clinical Guidelines 2010 4
Education Describe natural history of PE Modifying risk factors weight and exercise Contraception Travel- hydration, stockings, mobility, aisle seat,?consider enoxaparin for flights > 4hrs Post Thrombotic Syndrome discussed, legs assessed, Class II below knee stockings for 2 years post event (new evidence doesn t support) Following PE Perfusion defects resolve in 50% after one month of Rx Complete resolution in two thirds Post thrombotic syndrome occurs in 10-50% Approximately 4% of patients progress to CTEPH post PE at the 2 years mark Pengo V et al. N Engl J Med 2004;350:2257-2264 Chronic thromboembolic pulmonary hypertension CTEPH Part due to failure of endogenous lysis Part due to vascular remodelling Results in raised pulmonary vascular resistance and hence pulmonary hypertension Untreated progresses to right heart failure and death Follow up RH injury Length of anticoagulation For provoked event 3-6 months Consider long term for unprovoked event, particularly in men Consider long term in those with life threatening PE D-dimer and Factor VIII levels 4 weeks post stopping anticoagulation in those with unprovoked event- predicts increased risk of recurrence Follow-up Early CNS review*** Consultant led PE clinic Fast track to Thrombophilia service Nurse led PE clinic Telephone follow-up Virtual being developed All patients for 2 years At 2 years- questionnaire 5
Summary Stratify risk of early death Assess RH injury Low risk may be managed as an outpatient Provoked/ unprovoked Assess recurrence risk Tailor anticoagulation accordingly In keeping with emphasis on personalised medicine References Baglin T et al. Clinical guidelines for testing for heritable thrombophilia. British Journal Haematology 2010;149:209-220. Haspel J et al. Long-term anticoagulant therapy for idiopathic pulmonary pulmonary embolism in the elderly. A Decision Analysis. Chest 2009;135:1243-1251. Kline J et al. Prospective Evaluation of Right Ventricular Function and Functional Status Six Months After Acute Submassive Pulmonary Embolism. Chest 2009;136(5):1202-1210. Pengo V et al. Incidence of Chronic Thromboembolic Pulmonary Hypertension after Pulmonary Embolism. N Engl J Med 350;22:2257-2264. Kearon C. Natural History of Venous Thromboembolism. Circulation 2003;107;I-22-I-30. The End Any questions? 6