Common Pulmonary Embolus (PE)exam questions for medical finals, OSCEs and MRCP PACES
What are the risk factors for pulmonary embolus (PE)?
- Previous VTE
- Age > 60
- Prolonged travel
- Acute medical illness
- Surgery – especially lower limb orthopaedic surgery
What is the Well’s score in pulmonary embolism (PE)?
- The Well’s score assesses the probability of PE with given presentations.
- The score it gives defines probability of PE
- This then dictates further investigations.
|Clinically suspected DVT||3|
|Alternative diagnosis less likely than PE||3|
|Immobilisation/surgery in previous four weeks||1.5|
|History of DVT or PE||1.5|
|Malignancy (treatment in preceding 6 months or palliative stage)||1|
- 0-4: PE unlikely
- Do a D-Dimer – if negative, look for other causes of symptoms·
- > 4 = PE likely
- Do a CTPA or V/Q scan
What are the chances of malignancy in pulmonary embolus?
- If patient over 40 then there is a 10-25% chance of malignancy
- Therefore ensure thorough history, examination, CXR and bloods
- Organise CT abdo/pelvis plus PSA in men, mammography in women
What potential strategies are there for patients who develop PE despite adequate anti-coagulation?
- Increase INR target to 3-4
- Switch to LMWH
- IVC filter
Who should have thrombophilia testing after a PE?
- Do not offer to patients who are continuing on anti-coagulation treatment: only in patients whom there is a plan to stop anti-coagulation
- Consider testing for anti-phospholipid in patients with unprovoked PE
- Consider testing for hereditary thrombophilia in patient with unprovoked PE with first degree relatives who have a history of VTE
- See haematology pages for further details
Is there any evidence for thrombolysis in stable patients who have evidence of right ventricular dysfunction?
- Solid evidence of the benefit of this is still lacking
- However some centres have started to do it as it appears that the risks of thrombolysis may not be as great as previously thought