Pulmonary Embolism & Deep Vein Thrombosis - Handout.pdf

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Aims and objectives
•Cover pathophysiology, risk factors, and management of PE and DVT
•NICE (2020) guidelines
•High-yieldfactsthatare relevant for exams
•Duration:60 mins
•Slides and recordings: app.bitemedicine.com

3. Historyandexamination
A 65-year-old female presents with sudden onset
shortness of breath and pleuritic chest pain.
She has a history of a right-sided mastectomy for
breast cancer, 1 year ago. She is not on any
medications.
She has a BMI of 27.
Observations
HR 105, BP 85/60, RR 28, SpO
2 89%, Temp 37.7
3
Case-based discussion: 1

4. 4
A 65-year-old female presents with sudden onset shortness of breath and pleuritic chest pain.
She has a history of a right-sided mastectomy for breast cancer, 1 year ago. She is not on any
medications.
She has a BMI of 27.
Observations
HR 105, BP 85/60, RR 28, SpO
2 89%, Temp 37.7
Which of the following risk factors does this patient have for developing a PE?
Case History
Female
Previous breast cancer
65-years-old
BMI27
Previous surgery
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Q1 Q2 Q3 Q4

5. Historyandexamination
A 65-year-oldfemale presents with sudden onset
shortness of breath and pleuritic chest pain.
She has a history of a right-sided mastectomy for
breast cancer, 1 year ago. She is not on any
medications.
She has a BMI of 27.
Observations
HR 105, BP 85/60, RR 28, SpO
2 89%, Temp 37.7
5
Case-based discussion: 1

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Introduction
Definition
•Venousthromboembolism(VTE):any thromboembolic event occurring within the venous system,
including DVT and PE
•Deep vein thrombosis: thrombus in a deep vein, which partially or completely obstructs blood flow
•Pulmonaryembolism: one or more emboli, usually arising from a DVT,obstructing the pulmonary
arterial system
Epidemiology
•VTE is the third most common cardiovascular disease after MI and stroke (NICE)
•~50000casesofPEin2013-2014

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Pathophysiology: DVT and PE
Virchow’s triad
Hypercoagulability
•Increased platelet adhesionandclottingtendency
Venousstasis
•Blood flow isnormally laminarand ensures platelets and clotting factors are
dispersed and not activated
•Stasisdisrupts this and promotes thrombus formation
Endothelialdamage
•Endothelial cellsnormally prevent thrombosisby secreting anticoagulants, as well
as blocking exposure to pro-thrombotic collagen
•Damage, inflammation or trauma disrupts this
DVT:thrombus typically forms in the deep veins of the legs
PE:thrombustypicallyembolisesfromaDVT
•Thrombi can rarely develop within the pulmonary vasculature

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Pathophysiology: DVT and PE

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Pathophysiology: PE

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Clinical features: PE
Symptoms Signs
Pleuritic chest pain Tachycardia
Dyspnoea Hypoxia
Cough or haemoptysis Hypotension
•SBP < 90mmHg suggests massive PE
Fever Elevated JVP: suggests corpulmonale
Syncope Deep vein thrombosis: swollen, tender calf

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Wells score: PE
Wells Score
Clinical feature Points
Clinical signs and symptoms of a DVT 3.0
PE is number 1 diagnosis or equally likely 3.0
Tachycardia(>100 BPM) 1.5
Immobilisationfor more than three days or surgeryin the previous
four weeks
1.5
Previous, objectively diagnosed PE orDVT 1.5
Malignancywith treatment within the last 6 months, orpalliative 1.0
Haemoptysis 1.0
> 4: Likely PE
≤ 4: Unlikely PE

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The patient has had a CXR (normal) and ECG (sinus tachycardia). What is your next investigation?
Case History
CTPA
V/Q scan
D-dimer
Pulmonaryangiogram
FBCapp.bitemedicine.com
Q2Q1
A 65-year-old female presents with sudden onset shortness of breath and pleuritic chest pain.
She has a history of a right-sided mastectomy for breast cancer, 1 year ago. She is not on any
medications.
She has a BMI of 27.
Observations
HR 105, BP 85/60, RR 28, SpO
2 89%, Temp 37.7
Q3 Q4

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Investigations: PE
Bedside
•ECG: sinus tachycardia (most common); RBBB and right axis deviation; S1Q3T3
Bloods
•ABG: may demonstrate respiratory failure
Imaging
•CXR: typically normal, although a wedge-shaped opacification can be seen
•ECHO: assess for right ventricular strain in massive PE
Further tests:depends on Wells score
•CTPA is performed if highprobability (Wells score > 4) or
•D-dimer performed if lowprobability (Wells score ≤ 4)
•V/Qscanisanalternative to CTPA if CTPA is not appropriate

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Investigations: PE

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Investigations: PE
(1)

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Investigations: PE
(2)

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Investigations: PE
Suspected PE in pregnancy
•Clinical features of DVT: an ultrasound of the legs should be performed
•If a DVT is confirmed,no further investigationsare needed, and the patient should be
anticoagulated
•Without features of a DVT: a V/Q ora CTPA scan can be performed (depending on local guidelines)
•CXR has features suggestive of PE:a CTPA should be performed in preference to a V/Q scan
•CTPA:greater risk to mother
•V/Qscan:greaterrisktofoetus
•The above is based on RCOG guidelines (2015)

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CTPA confirms a PE. Which of the following would you start in this patient?
Case History
Warfarin
LMWH
Warfarin and LMWH
Apixaban
Alteplase
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Q2Q1 Q3 Q4
A 65-year-old female presents with sudden onset shortness of breath and pleuritic chest pain.
She has a history of a right-sided mastectomy for breast cancer, 1 year ago. She is not on any
medications.
She has a BMI of 27.
Observations
HR 105, BP 85/60, RR 28, SpO
2 89%, Temp 37.7

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Management: PE
Massive PE
•Thrombolysis: e.g.alteplase ifthere is evidence of haemodynamic instability (SBP <
90mmHg) and/or respiratory distress
Non-massive PE
•Anticoagulation:
•DOAC, e.g. rivaroxaban orapixaban, ispreferred (NICE 2020)
•LMWH or warfarin may be used if intolerant to DOAC or in renal impairment
•Provoked:considerstoppingtreatmentat3months
•Unprovoked:considercontinuingbeyond3months
•Activecancer:treatfor3-6months
Provoked PEis associated with a transient risk factor within theprevious 3 months, such as
significant immobility, surgery, trauma or pregnancy
Unprovoked PE does not fulfil the above

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Management: PE
Alternative treatments
•Inferior vena cava filter: consider in patients with recurrent PEs, despite anticoagulation
•Percutaneous catheter directed thrombolysis: can be carried out as an alternative to systemic
thrombolysis
•Surgical embolectomy: when thrombolysis has failed or is contraindicated

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What additional investigations should you carry out in this patient?
Case History
CT head
Abdominal ultrasound
CT abdomen and pelvis
AXR
None of the above
app.bitemedicine.com
Q2Q1 Q3 Q4
A 65-year-old female presents with sudden onset shortness of breath and pleuritic chest pain.
She has a history of a right-sided mastectomy for breast cancer, 1 year ago. She is not on any
medications.
She has a BMI of 27.
Observations
HR 105, BP 85/60, RR 28, SpO
2 89%, Temp 37.7

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Follow-up: PE
Investigation for cancer:
•All patients:all patients with an unprovoked PE should be examined and have a full set of blood tests
•NICE (2020) suggests that patientsdo not need further investigationunless they have signs or
symptoms of cancer
•This is in contrast toprevious guidance which advised CT imaging in those above 40 years of age
Investigations for thrombophilia:
•Antiphospholipid antibodies:unprovoked PEANDwhere there is a plan to stop anticoagulation
•Thrombophilia screen:unprovoked PEANDa first-degree relative who has had PEANDthere is a plan
to stop anticoagulation
Provoked PEis associated with a transient risk factor within theprevious 3 months,
such as significant immobility, surgery, trauma or pregnancy
Unprovoked PE does not fulfil the above

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Complications
Complications
Cor pulmonale
Pulmonary infarction
Cardiac arrest
Heparin-associated thrombocytopenia

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Differential diagnosis: PE
Pulmonary embolism Pneumothorax Pneumonia
•SOB
•Pleuritic chest pain
•Haemoptysis
•Pain / swelling in one leg
•SOB
•Pleuritic chest pain
•SOB
•Pleuritic chest pain
•Productive cough
•Fever
•Risk factors for
thromboembolism
•Virchow’s triad
•Any age
•Primaryspontaneous
•Secondaryspontaneous
•Tension
•Usually middle-aged or
elderly
•More common with
underlying lung disease
ECGusually non-specific, but
sinus tachycardia and S1Q3T3
Confirmed on CTPA
Confirmed on CXR Usually confirmed on CXR

25. Historyandexamination
A50-year-oldmanpresentswithaswollenand
painfulrightcalf.Heisanactivesmokerandis
currentlybeingtreatedforlungcancer.
Observations
HR 90, BP 115/72, RR 20, SpO
2 99%, Temp 37.3
25
Case-based discussion: 2
(3)

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Clinical features: DVT
Symptoms Signs
Unilateralcalf pain, erythema, swelling Tender and swollen calf
Peripheral oedema
Distention of superficial veins

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Clinical features: DVT
(3)

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Wells score: DVT
Wells Score
Clinical feature Points
Active cancer
+1
Bedridden or recent major surgery
+1
Calf swelling > 3cm compared to the other leg
+1
Superficial veins (non-varicose) present +1
Entire leg swollen +1
Tendernessalong veins +1
Pitting oedemaof the affected leg +1
Immobilityof affected leg, e.g. plaster +1
Previous DVT +1
Alternative diagnosis likely -2
> 1: Likely DVT
≤ 1: Unlikely DVT

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A50-year-oldmanpresentswithaswollenandpainfulrightcalf.Heisanactive
smokerandiscurrentlybeingtreatedforlungcancer.
Observations
HR 90, BP 115/72, RR 20, SpO
2 99%, Temp 37.3
The patient has a Wells score of 2. What is your next step?
Case History
D-dimer
CTPA
Duplex ultrasound of the leg
CXR
Discharge home
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Q1

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Investigations: DVT
DVT likely (Wells score > 1)
•Duplex USS within 4 hours: diagnostic investigation
•D-dimer if USS notpossiblewithin4hours
•Offerinterimanticoagulation
•Perform USS within 24 hours
DVT unlikely (Wells score ≤ 1)
•D-dimer
•Raised: perform duplex USS as above
•Normal: consider alternative diagnosis
•IftheD-dimerresultisnotavailablein4hours,offerinterimanticoagulation

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Investigations: DVT

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Management: DVT
•Anticoagulation:
•DOAC, e.g. rivaroxaban or apixaban, is preferred (NICE 2020)
•LMWH or warfarin may be used if intolerant to DOAC or in renal impairment
•Provoked: consider stopping treatment at 3 months
•Unprovoked: consider continuing beyond 3 months
•Active cancer: treat for 3-6 months

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Follow-up: DVT
Investigation for cancer:
•All patients:all patients with an unprovoked DVT should be examined and have a full set of blood tests
•NICE (2020) suggests that patientsdo not need further investigationunless they have signs or
symptoms of cancer
•This is in contrast toprevious guidance which advised CT imaging in those above 40 years of age
Investigations for thrombophilia:
•Antiphospholipid antibodies:unprovoked DVTANDwhere there is a plan to stop anticoagulation
•Thrombophilia screen:unprovoked DVTANDa first-degree relative who has had DVT/PEANDthere
is a plan to stop anticoagulation
Provoked DVTis associated with a transient risk factor within theprevious 3 months,
such as significant immobility, surgery, trauma or pregnancy
Unprovoked DVT does not fulfil the above

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Complications
Complications
Pulmonary embolism
Post thrombotic syndrome
Phlegmasia ceruladolens
•Massive DVT
•Obstruction of venous inflow and arterial
outflow
•Leads to ischaemic limb
Heparin-induced thrombocytopaenia

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Differential diagnosis: DVT
DVT Cellulitis
Painful, swollen leg
Erythema
Painful, swollen leg
Erythema
•Borders more defined
Fever, tachycardia, hypotension
Virchow's triad Elderly
Diabetes
Immunocompromised
Lymphoedema
Raised D-dimer
USS is diagnostic
Raised WCC and CRP
D-dimer may also be raised

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Top-decile question

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Recap
•Risk factor for thrombus formation: Virchow’s triad
•PE usually arises from a DVT
•Wells score is essential in determining next steps
•CTPAis diagnostic for PE
•Duplex USS is diagnostic for DVT
•DOACisfirstlineanticoagulant
•ThrombolysisisusedinhaemodynamicallyunstablepatientswithaPE

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References
1.R.W.Koster / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)
2.James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)
3.James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)
All other images were made by BiteMedicineand not suitable for redistribution.

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