Who is at the highest risk? 3 points each – Cancer – Prior VTE – Hypercoagulability 2 points – Major surgery 1 point each – Age >70 – Obesity (BMI >29) – Bed rest – HRT or COC Increased risk >4 points at any time point after admission Kucher, N. et al. N Engl J Med 2005;352:

Simplified PESI Retrospective analysis of RIETE registry – Age >801 p –History of Cancer 1 p –Chron cardiopulmonary dis.1 p –Pulse >110 1 p –CHF1 p –SBP <100 1 p –SaO 2 <90%1 p 0 = low risk, 1 or more = high risk Jiménez D et al. Arch Intern Med. 2010;170:1383-9

Summary Diagnostic Rules PESI/sPESI most validated – 7 items HESTIA more complex – 11 items ESC is minimalistic, although requires asessment of RV dysfunction, perhaps more dependent on how the physician assesses

Acute treatment algorithm Hemodynamic Instability (shock) t-PA Large PE But stable Heparin IV  LMWH Submassive PE Rivaroxaban 15 mg bid  20 mg q.d. Vitamin K antagonist LMWH therap dose  cancer

Rivaroxaban - Important to know Starting dose 15 mg BID Switch after 3 weeks to 20 mg daily Must be taken with food Tablets contain lactose (some get stomach pain) Severe renal failure (CrCl <30 mL/min) or concomitant ketokonazole or other azoles, rifampicin and ritonavir are contraindications Few of the study patients hade extensive DVT or large PE. These patients might benefit from intial parenteral Rx.