Pulmonary Embolism 101 Alex Rankin, MD

Learning Objectives Better understanding of diagnosis and management of acute PE Recognize acute PE Learn how to Test Learn how to Treat

Take Home Points PE can present as anything Use Wells +/- PERC +/- Ddimer Consider Age Adjusted Ddimer Be cautious in your imaging Be cautious in your treatment

Definition/ What We’ll Cover PE= obstruction of Pulmonary Artery/branch by embolism originating elsewhere Emboli: Air, Fat, Tumor, Thrombus Subtypes: Acute, Subacute (days/weeks), Chronic Presentation: Hemodynamically Stable or Unstable Won’t cover: Pregnancy, Malignancy, VTE prophylaxis

CasePresentation Nurse calls 3am Cross Cover 65 y/o female with chest pain Hospital day #5 for gallstone pancreatitis, slow to progress with diet. Nonsmoker, no cardiac hx, no DM, HTN, no FMHx CAD You astutely list Pulmonary Embolism as possible Differential Diagnosis Why did you think that? Now what do you do?

Clinical Presentation of PE Anything! Most Common: Dyspnea Pleuritic Chest Pain Cough (hemoptysis less common)

Clinical Presentation of PE Anything! - Take away Point #1 Most Common: Dyspnea Pleuritic Chest Pain Cough (hemoptysis less common)

Workup of PE Assess clinical stability CXR, EKG Labs: CBC, BMP, LFTs, INR, ABG

Classic Imaging Findings Hamptons Hump An anterior-posterior chest radiograph of a patient with suspected pulmonary embolus. Image A shows a wedge-shaped defect in the lateral segment of the middle lobe (arrow). Image B is a CT scan through the mid chest and shows the corresponding wedge-shaped defect (arrowhead) and thrombus in the pulmonary arteries subtending the middle lobe (arrows). https://www.uptodate.com/contents/image?imageKey=RADIOL%2F97988&topicKey=PULM%2F8261&source=outline_link&search=pulmonary%20embolism&selectedTitle=3~150

Classic Imaging Findings Westermark Sign A magnified A-P view of the left lung (A) shows a region of oligemia in the left lower chest (asterisk) in a patient with occlusive pulmonary embolism. Image B is a further magnification showing normal vasculature in the upper and lower lung regions but oligemia in the middle section (asterisk). The CT scan (C) shows a large saddle embolus of the left main pulmonary artery (arrow) https://www.uptodate.com/contents/image?imageKey=RADIOL%2F98271&topicKey=PULM%2F8261&source=outline_link&search=pulmonary%20embolism&selectedTitle=3~150

Classic EKG Findings Sinus Tachycardia (most common) RV Strain (T wave inversions V1-4, inferior leads) RBBB RAD Nonspecific ST/T changes SI, QIII, TIII (only 10% of pts with PE)

https://lifeinthefastlane.com/ecg-library/pulmonary-embolism/

How to Test for PE 1. Start with a Clinical Decision Support tool CDS has higher specificity for excluding PE over Clinician Gestalt when used with DDimer Ann Intern Med. 2011 Oct 4;155(7):448-60.

Wells Score https://www.uptodate.com/contents/image?imageKey=PULM%2F54767&topicKey= PULM%2F8261&rank=3~150&source=see_link&search=pulmonary%20embolism

Wells Score Low Probability--Use PERC Score Low Prob + PERC (-): Sensitivity 97.4%, Specificity 21.9%, False Neg rate 1.0% J Thromb Haemost 2008; 6: 772–80.

Wells Score Low Probability—Use PERC Score --If ALL negative, no further testing indicated --If ANY positive, get Ddimer  Imaging if Positive https://www.uptodate.com/contents/image?topicKey=8261&imageKey= PULM%2F94941&source=outline_link&search=pulmonary%20embolism

Wells Score Summary Low Prob (<2) Use PERC Intermediate Probability (Wells 2-6) Get Ddimer  Imaging if Positive High Probability (>6) Proceed straight to imaging

Wells Score Summary Take Away #2 Use Wells Score +/- PERC +/- Ddimer

Our Patient Wells score 4.5 Our pt: Moderate Probability HR >100 1.0 No other Dx more likely than PE3.0 Our pt: Moderate Probability Our pt: DDimer 680 Positive, but is it really positive?

Validated AgeX10 as Ddimer cut off for pts >50 y/o Age Adjusted Ddimer Prospective, non-randomized Validated AgeX10 as Ddimer cut off for pts >50 y/o JAMA. 2014;311(11):1117-1124. doi:10.1001/jama.2014.2135

Age-adjusted Ddimer increases specificity while preserving sensitivity BMJ 2013;346:f2492 doi: 10.1136/bmj.f2492 (Published 3 May 2013)

Back to our Patient Ddimer 680 Age: 65 Yes—this is positive Take Home #3: Consider Age Adjusted Ddimer Now what?

Take Away #3: Be cautious in your imaging Imaging studies CT Pulmonary Angiogram Need good kidneys Need to be stable for scan Ventilation/Perfusion Scan Need clear lungs Usually not stat study Bilateral lower extremity duplex ultrasound Echocardiogram? Take Away #3: Be cautious in your imaging

Our Patient Arrowheads: Intra luminal thrombi in right pulmonary artery branches Now what? http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/Medicine/PE1.htm

Acute PE Treatment Generally need admission PESI Score (30 day Mortality) Assess Bleeding risk Rambam Maimonides Med J. 2014 Oct; 5(4): e0037.

RIETE Study: Major Bleeding

RIETE Study: Major Bleeding 0 points: 0.3% bleeding risk 1-4 points: 2.6% >4 points: 7.3%

RIETE Study: Fatal Bleeding Nieto, José Antonio et al. Thrombosis Research , Volume 132 , Issue 2 , 175 - 179

RIETE Study: Fatal Bleeding

RIETE Study: Fatal Bleeding <1.5 points: 0.10% bleeding risk 1.5-4 points: 0.72% >4 points: 1.44%

Take Away #4: Be cautious in your treatment Acute PE Treatment Anticoagulation HeparinWarfarin Need to be inpatient for entire bridge Can stop quickly and reverse effect Enoxaparin Warfarin or lifetime Need to have good kidneys Direct Oral Anticoagulant? Need to have insurance Need to be compliant IVC filter/Embolectomy/tPA/etc Take Away #4: Be cautious in your treatment

Our patient Improved, Satisfied with her care, discharged home 5 days later. Anticoagulation clinic plans bridge for interval cholecystectomy Take Home Points PE can present as anything Use Wells +/- PERC +/- Ddimer Consider Age Adjusted Ddimer Be cautious in your imaging Be cautious in your treatment