Podcast
Questions and Answers
Which component is part of Virchow's Triad?
Which component is part of Virchow's Triad?
- Endothelial injury (correct)
- Renal Failure
- Hyperlipidemia
- Hypertension
Which of the following is considered a risk factor for venous thromboembolism (VTE)?
Which of the following is considered a risk factor for venous thromboembolism (VTE)?
- Hypothyroidism
- Malignancy (correct)
- Hypotension
- Hyperlipidemia
What is the primary effect of pulmonary embolism on ventilation and perfusion in the lungs?
What is the primary effect of pulmonary embolism on ventilation and perfusion in the lungs?
- Increased ventilation/perfusion matching.
- Reduced pulmonary vascular resistance.
- V/Q mismatch. (correct)
- Decreased alveolar dead space.
A patient presents with dyspnea, tachypnea, and pleuritic chest pain. Which of the following findings would be most suggestive of a pulmonary embolism?
A patient presents with dyspnea, tachypnea, and pleuritic chest pain. Which of the following findings would be most suggestive of a pulmonary embolism?
What is a normal A-a gradient on room air?
What is a normal A-a gradient on room air?
What arterial blood gas (ABG) findings are typical in a patient with a pulmonary embolism (PE)?
What arterial blood gas (ABG) findings are typical in a patient with a pulmonary embolism (PE)?
Which diagnostic study is considered the gold standard for evaluating pulmonary embolism, despite being invasive?
Which diagnostic study is considered the gold standard for evaluating pulmonary embolism, despite being invasive?
What is the primary utility of the PERC rule in evaluating possible pulmonary embolism (PE)?
What is the primary utility of the PERC rule in evaluating possible pulmonary embolism (PE)?
A patient is being evaluated for a suspected pulmonary embolism (PE). According to the guidelines, when is D-dimer testing most appropriate?
A patient is being evaluated for a suspected pulmonary embolism (PE). According to the guidelines, when is D-dimer testing most appropriate?
What radiographic finding on a chest X-ray is suggestive of pulmonary embolism?
What radiographic finding on a chest X-ray is suggestive of pulmonary embolism?
What is the primary role of a V/Q scan in the evaluation of pulmonary embolism (PE)?
What is the primary role of a V/Q scan in the evaluation of pulmonary embolism (PE)?
In risk stratification for pulmonary embolism (PE), what is the key characteristic of low-risk patients?
In risk stratification for pulmonary embolism (PE), what is the key characteristic of low-risk patients?
Which initial treatment is typically appropriate for a patient with a low-risk pulmonary embolism?
Which initial treatment is typically appropriate for a patient with a low-risk pulmonary embolism?
A patient with a confirmed pulmonary embolism (PE) is hypotensive. Which of the following is the MOST appropriate initial intervention?
A patient with a confirmed pulmonary embolism (PE) is hypotensive. Which of the following is the MOST appropriate initial intervention?
What is the purpose of an IVC filter in the management of venous thromboembolism (VTE)?
What is the purpose of an IVC filter in the management of venous thromboembolism (VTE)?
A patient with a pulmonary embolism (PE) has a contraindication to anticoagulation. What intervention should be considered?
A patient with a pulmonary embolism (PE) has a contraindication to anticoagulation. What intervention should be considered?
A patient is diagnosed with a provoked VTE, related to a recent surgery. How long should the patient be on anticoagulation?
A patient is diagnosed with a provoked VTE, related to a recent surgery. How long should the patient be on anticoagulation?
When transitioning a patient from heparin to warfarin for long-term anticoagulation, what is the recommended duration of overlap between the two medications?
When transitioning a patient from heparin to warfarin for long-term anticoagulation, what is the recommended duration of overlap between the two medications?
For a pregnant patient diagnosed with VTE, which anticoagulant is the MOST appropriate for long-term use?
For a pregnant patient diagnosed with VTE, which anticoagulant is the MOST appropriate for long-term use?
Which of the following is a common symptom associated with pulmonary embolism (PE)?
Which of the following is a common symptom associated with pulmonary embolism (PE)?
Which of the following is LEAST likely to be associated with the development of deep vein thrombosis (DVT)?
Which of the following is LEAST likely to be associated with the development of deep vein thrombosis (DVT)?
Which of the following is the MOST appropriate initial test for a patient with a low probability Well's score?
Which of the following is the MOST appropriate initial test for a patient with a low probability Well's score?
Which of the following is the mechanism of action of Fondaparinux?
Which of the following is the mechanism of action of Fondaparinux?
A 70-year-old male with multiple comorbidities and a creatinine clearance of 20 mL/min is diagnosed with a pulmonary embolism. Which of the following anticoagulants should be avoided?
A 70-year-old male with multiple comorbidities and a creatinine clearance of 20 mL/min is diagnosed with a pulmonary embolism. Which of the following anticoagulants should be avoided?
Systemic thrombolysis is only indicated for:
Systemic thrombolysis is only indicated for:
According to CHEST guidelines, what direct oral anticoagulant (DOAC) would be appropriate for treating patients who have been initially treated with a parenteral anticoagulant?
According to CHEST guidelines, what direct oral anticoagulant (DOAC) would be appropriate for treating patients who have been initially treated with a parenteral anticoagulant?
For a patient with a confirmed diagnosis of Pulmonary Embolism who is also diagnosed with cancer, what would be the most appropriate anticoagulation therapy?
For a patient with a confirmed diagnosis of Pulmonary Embolism who is also diagnosed with cancer, what would be the most appropriate anticoagulation therapy?
Which of the following is an absolute contraindication to thrombolysis?
Which of the following is an absolute contraindication to thrombolysis?
A patient on long-term anticoagulation is experiencing recurrent VTE despite being compliant with their medications. What would be the MOST appropriate next step in management?
A patient on long-term anticoagulation is experiencing recurrent VTE despite being compliant with their medications. What would be the MOST appropriate next step in management?
What is the most important measure for venous thromboembolism?
What is the most important measure for venous thromboembolism?
What radiographic findings are suggestive of PE?
What radiographic findings are suggestive of PE?
According to the presented material, beyond anticoagulation and thrombolysis, which interventional technique is listed as potential advanced therapy for VTE?
According to the presented material, beyond anticoagulation and thrombolysis, which interventional technique is listed as potential advanced therapy for VTE?
A 60-year-old patient with a history of recurrent unprovoked VTEs despite adequate anticoagulation is being considered for long-term management. Which of the following interventions is LEAST likely to be beneficial?
A 60-year-old patient with a history of recurrent unprovoked VTEs despite adequate anticoagulation is being considered for long-term management. Which of the following interventions is LEAST likely to be beneficial?
Which of the following DOACs has a direct reversal agent, Praxbind?
Which of the following DOACs has a direct reversal agent, Praxbind?
Which of the following best represents a Well's score indicating 'high probability' of PE?
Which of the following best represents a Well's score indicating 'high probability' of PE?
A 55-year-old patient develops a saddle PE and is hypotensive. What advanced VTE treatment is indicated?
A 55-year-old patient develops a saddle PE and is hypotensive. What advanced VTE treatment is indicated?
In terms of D-dimer, which of the following statements is correct?
In terms of D-dimer, which of the following statements is correct?
Considering the information provided, which of the following suggests a major pathologic effect from PE?
Considering the information provided, which of the following suggests a major pathologic effect from PE?
Which of the following is a recognized approach to deal with Catheter Techniques, regarding PE?
Which of the following is a recognized approach to deal with Catheter Techniques, regarding PE?
What is the approximate percentage of pulmonary embolism (PE) patients who present with dyspnea?
What is the approximate percentage of pulmonary embolism (PE) patients who present with dyspnea?
What is the upper limit of normal for the A-a gradient while breathing room air?
What is the upper limit of normal for the A-a gradient while breathing room air?
Which of the following is a typical finding on arterial blood gas (ABG) analysis in a patient with a pulmonary embolism (PE)?
Which of the following is a typical finding on arterial blood gas (ABG) analysis in a patient with a pulmonary embolism (PE)?
What is the formula used to calculate the alveolar-arterial (A-a) gradient?
What is the formula used to calculate the alveolar-arterial (A-a) gradient?
What finding on physical exam is MOST suggestive of a pulmonary embolism?
What finding on physical exam is MOST suggestive of a pulmonary embolism?
A patient suspected of having a PE needs further diagnostic evaluation. Initial testing reveals an elevated D-dimer. What is the next step in the diagnostic process?
A patient suspected of having a PE needs further diagnostic evaluation. Initial testing reveals an elevated D-dimer. What is the next step in the diagnostic process?
Which of the following radiographic findings on a chest X-ray is LEAST likely to be associated with pulmonary embolism?
Which of the following radiographic findings on a chest X-ray is LEAST likely to be associated with pulmonary embolism?
In the context of pulmonary embolism, what does the term 'massive PE' typically indicate?
In the context of pulmonary embolism, what does the term 'massive PE' typically indicate?
Which of the following is an expected finding on EKG for a patient diagnosed with PE?
Which of the following is an expected finding on EKG for a patient diagnosed with PE?
Which of the following statements regarding the use of D-dimer testing in the evaluation of pulmonary embolism (PE) is MOST accurate?
Which of the following statements regarding the use of D-dimer testing in the evaluation of pulmonary embolism (PE) is MOST accurate?
According to the PERC rule, which of the following criteria would allow clinicians to rule out PE?
According to the PERC rule, which of the following criteria would allow clinicians to rule out PE?
Which of the following is a risk factor for venous thromboembolism (VTE) that is specific to women?
Which of the following is a risk factor for venous thromboembolism (VTE) that is specific to women?
For a patient with a confirmed diagnosis of Pulmonary Embolism, but has a contraindication to anticoagulation, what would be an appropriate alternative treatment?
For a patient with a confirmed diagnosis of Pulmonary Embolism, but has a contraindication to anticoagulation, what would be an appropriate alternative treatment?
When initiating Warfarin, what is the appropriate target INR for treating PE?
When initiating Warfarin, what is the appropriate target INR for treating PE?
Which of the following best describes the primary role of V/Q scanning in the diagnosis of pulmonary embolism (PE)?
Which of the following best describes the primary role of V/Q scanning in the diagnosis of pulmonary embolism (PE)?
Which of the following is the MOST accurate statement regarding the use of thrombolysis in patients with pulmonary embolism (PE)?
Which of the following is the MOST accurate statement regarding the use of thrombolysis in patients with pulmonary embolism (PE)?
Following initial treatment with a parenteral anticoagulant, which of the following direct oral anticoagulants (DOACs) can be used for long-term anticoagulation?
Following initial treatment with a parenteral anticoagulant, which of the following direct oral anticoagulants (DOACs) can be used for long-term anticoagulation?
After diagnosing a PE, the physician determines the patient will be discharged and managed as an outpatient. She wants to prescribe a DOAC, but also wants to be prepared to control bleeding if it occurred. Which of the following DOACs has a direct reversal agent?
After diagnosing a PE, the physician determines the patient will be discharged and managed as an outpatient. She wants to prescribe a DOAC, but also wants to be prepared to control bleeding if it occurred. Which of the following DOACs has a direct reversal agent?
Which of the following patients with a confirmed acute pulmonary embolism (PE) would be the MOST appropriate candidate for systemic thrombolysis?
Which of the following patients with a confirmed acute pulmonary embolism (PE) would be the MOST appropriate candidate for systemic thrombolysis?
In a patient with recurrent venous thromboembolism (VTE) despite adequate anticoagulation with LMWH, what is the MOST appropriate next step in management?
In a patient with recurrent venous thromboembolism (VTE) despite adequate anticoagulation with LMWH, what is the MOST appropriate next step in management?
Which of the following is the MOST appropriate long-term anticoagulation strategy for a pregnant patient diagnosed with VTE?
Which of the following is the MOST appropriate long-term anticoagulation strategy for a pregnant patient diagnosed with VTE?
A patient is diagnosed with a provoked VTE secondary to a recent surgery. According to current guidelines, what is the MINIMUM recommended duration of anticoagulation therapy, assuming no ongoing risk factors?
A patient is diagnosed with a provoked VTE secondary to a recent surgery. According to current guidelines, what is the MINIMUM recommended duration of anticoagulation therapy, assuming no ongoing risk factors?
A 35-year-old female presents with pleuritic chest pain, shortness of breath, and a history of recent long-distance travel. Her vital signs are stable. Her Well's score is 2.0. Which of the following is the MOST appropriate next step in evaluating her for a possible pulmonary embolism?
A 35-year-old female presents with pleuritic chest pain, shortness of breath, and a history of recent long-distance travel. Her vital signs are stable. Her Well's score is 2.0. Which of the following is the MOST appropriate next step in evaluating her for a possible pulmonary embolism?
A 50-year-old male presents with acute dyspnea and is found to have a large saddle pulmonary embolism causing right ventricular dysfunction but maintaining a normal blood pressure. Which of the following treatment approaches is MOST appropriate?
A 50-year-old male presents with acute dyspnea and is found to have a large saddle pulmonary embolism causing right ventricular dysfunction but maintaining a normal blood pressure. Which of the following treatment approaches is MOST appropriate?
What is a key characteristic that defines a 'low-risk' pulmonary embolism (PE)?
What is a key characteristic that defines a 'low-risk' pulmonary embolism (PE)?
A patient is diagnosed with a provoked VTE related to a recent surgery. What duration of anticoagulation is typically recommended?
A patient is diagnosed with a provoked VTE related to a recent surgery. What duration of anticoagulation is typically recommended?
Which radiographic finding on a chest X-ray is LEAST likely to be associated with pulmonary embolism?
Which radiographic finding on a chest X-ray is LEAST likely to be associated with pulmonary embolism?
Which of the following statements is MOST accurate regarding the use of thrombolysis in patients with pulmonary embolism (PE)?
Which of the following statements is MOST accurate regarding the use of thrombolysis in patients with pulmonary embolism (PE)?
What upper limit of normal is accepted for the A-a gradient while breathing room air?
What upper limit of normal is accepted for the A-a gradient while breathing room air?
Following initial treatment with a parenteral anticoagulant, which of the following direct oral anticoagulants (DOACs) is approved for long term oral anticoagulation?
Following initial treatment with a parenteral anticoagulant, which of the following direct oral anticoagulants (DOACs) is approved for long term oral anticoagulation?
Beyond anticoagulation and thrombolysis, which interventional technique is listed as potential advanced therapy for VTE?
Beyond anticoagulation and thrombolysis, which interventional technique is listed as potential advanced therapy for VTE?
Which of the following is a component of Virchow's Triad?
Which of the following is a component of Virchow's Triad?
Which of the choices is a typical sign or symptom of PE?
Which of the choices is a typical sign or symptom of PE?
According to information in the slides, which therapy is appropriate for a pregnant patient with VTE?
According to information in the slides, which therapy is appropriate for a pregnant patient with VTE?
If a patient's medical history includes prolonged immobility after a major surgery, which element of Virchow's Triad is most directly relevant to their increased risk of VTE?
If a patient's medical history includes prolonged immobility after a major surgery, which element of Virchow's Triad is most directly relevant to their increased risk of VTE?
Which of the following is NOT a Vitamin K antagonist?
Which of the following is NOT a Vitamin K antagonist?
Which test is typically used to evaluate a patient with an elevated D-dimer for a PE?
Which test is typically used to evaluate a patient with an elevated D-dimer for a PE?
Which condition is a classic part of Virchow's Triad?
Which condition is a classic part of Virchow's Triad?
Which of the following describes a 'Saddle Embolus'?
Which of the following describes a 'Saddle Embolus'?
What is the appropriate long-term anticoagulation strategy for a pregnant patient diagnosed with VTE?
What is the appropriate long-term anticoagulation strategy for a pregnant patient diagnosed with VTE?
According to Virchow's Triad, which of the following is a primary factor contributing to the formation of venous thromboembolism (VTE)?
According to Virchow's Triad, which of the following is a primary factor contributing to the formation of venous thromboembolism (VTE)?
Which condition is most likely to cause stasis, a component of Virchow's triad?
Which condition is most likely to cause stasis, a component of Virchow's triad?
Which of the following is a hypercoagulable state that increases the risk of VTE?
Which of the following is a hypercoagulable state that increases the risk of VTE?
A patient with a history of malignancy is at an increased risk for VTE due to:
A patient with a history of malignancy is at an increased risk for VTE due to:
Which of the following is a recognized risk factor for VTE specific to women?
Which of the following is a recognized risk factor for VTE specific to women?
The most common symptom of a pulmonary embolism is:
The most common symptom of a pulmonary embolism is:
Which of the following is a typical finding on physical examination of a patient with a pulmonary embolism?
Which of the following is a typical finding on physical examination of a patient with a pulmonary embolism?
In a patient with a suspected pulmonary embolism, an increased alveolar-arterial (A-a) gradient suggests:
In a patient with a suspected pulmonary embolism, an increased alveolar-arterial (A-a) gradient suggests:
The alveolar-arterial (A-a) gradient is calculated using:
The alveolar-arterial (A-a) gradient is calculated using:
Which of the following is the most typical finding on arterial blood gas (ABG) analysis in a patient with a PE?
Which of the following is the most typical finding on arterial blood gas (ABG) analysis in a patient with a PE?
Which of the following is the MOST common finding on EKG for a patient diagnosed with PE?
Which of the following is the MOST common finding on EKG for a patient diagnosed with PE?
What radiographic finding on a chest X-ray, while not always present, is highly suggestive of pulmonary embolism?
What radiographic finding on a chest X-ray, while not always present, is highly suggestive of pulmonary embolism?
A 'Hampton's Hump' seen on chest X-ray of a patient with PE is characterized by:
A 'Hampton's Hump' seen on chest X-ray of a patient with PE is characterized by:
What is the significance of a normal chest X-ray in the context of suspected pulmonary embolism?
What is the significance of a normal chest X-ray in the context of suspected pulmonary embolism?
In the context of diagnosing PE, what information does a lower extremity duplex ultrasound provide?
In the context of diagnosing PE, what information does a lower extremity duplex ultrasound provide?
In a CT Pulmonary Angiogram, what finding is most indicative of pulmonary embolism?
In a CT Pulmonary Angiogram, what finding is most indicative of pulmonary embolism?
What is the primary role of anticoagulation in the acute management of pulmonary embolism?
What is the primary role of anticoagulation in the acute management of pulmonary embolism?
According to guidelines, which factor is LEAST important when determining the duration of anticoagulation therapy after a provoked VTE?
According to guidelines, which factor is LEAST important when determining the duration of anticoagulation therapy after a provoked VTE?
Which of the following is TRUE regarding the treatment of pregnant patients with VTE?
Which of the following is TRUE regarding the treatment of pregnant patients with VTE?
Why are Direct Oral Anticoagulants (DOACs) preferred over Warfarin in most non-pregnant patients with PE
Why are Direct Oral Anticoagulants (DOACs) preferred over Warfarin in most non-pregnant patients with PE
For a patient with recurrent VTE despite adequate anticoagulation with LMWH, what action is most appropriate?
For a patient with recurrent VTE despite adequate anticoagulation with LMWH, what action is most appropriate?
Regarding thrombolysis for PE, what is a primary consideration for its use?
Regarding thrombolysis for PE, what is a primary consideration for its use?
A patient with known PE presents with active internal bleeding. Given this contraindication to anticoagulation, what is the MOST appropriate next step?
A patient with known PE presents with active internal bleeding. Given this contraindication to anticoagulation, what is the MOST appropriate next step?
Why is VTE prevention considered so critical?
Why is VTE prevention considered so critical?
A patient with a proximal DVT undergoes thrombolysis. Despite a successful procedure, they develop severe acute kidney injury. Which of the following anticoagulants is LEAST appropriate for long-term management?
A patient with a proximal DVT undergoes thrombolysis. Despite a successful procedure, they develop severe acute kidney injury. Which of the following anticoagulants is LEAST appropriate for long-term management?
A 65-year-old male post-hip replacement surgery develops acute-onset dyspnea, pleuritic chest pain, and tachycardia. His SpO2 is 88% on room air. What is the most likely underlying cause?
A 65-year-old male post-hip replacement surgery develops acute-onset dyspnea, pleuritic chest pain, and tachycardia. His SpO2 is 88% on room air. What is the most likely underlying cause?
Which of the following represents Virchow's Triad, the major contributors to venous thromboembolism (VTE)?
Which of the following represents Virchow's Triad, the major contributors to venous thromboembolism (VTE)?
A 40-year-old woman on oral contraceptives presents with sudden pleuritic chest pain and dyspnea. What is the most appropriate initial diagnostic step for a patient with a low clinical probability of PE?
A 40-year-old woman on oral contraceptives presents with sudden pleuritic chest pain and dyspnea. What is the most appropriate initial diagnostic step for a patient with a low clinical probability of PE?
Which of the following ECG findings is most classically associated with pulmonary embolism (PE)?
Which of the following ECG findings is most classically associated with pulmonary embolism (PE)?
Which chest X-ray (CXR) finding is most specific for pulmonary embolism (PE)?
Which chest X-ray (CXR) finding is most specific for pulmonary embolism (PE)?
A 57-year-old patient with a history of malignancy presents with dyspnea and pleuritic chest pain. His CTPA confirms a pulmonary embolism. What is the best long-term anticoagulation strategy?
A 57-year-old patient with a history of malignancy presents with dyspnea and pleuritic chest pain. His CTPA confirms a pulmonary embolism. What is the best long-term anticoagulation strategy?
A pregnant patient with a confirmed PE requires anticoagulation. What is the preferred therapy?
A pregnant patient with a confirmed PE requires anticoagulation. What is the preferred therapy?
A patient with massive PE presents with shock and hypotension. What is the best next step in management?
A patient with massive PE presents with shock and hypotension. What is the best next step in management?
A young patient with a low clinical probability of PE has a negative PERC score. What is the next step?
A young patient with a low clinical probability of PE has a negative PERC score. What is the next step?
Which of the following patients is a candidate for an IVC filter?
Which of the following patients is a candidate for an IVC filter?
A patient with an unprovoked PE is on rivaroxaban for 6 months. What is the next best step?
A patient with an unprovoked PE is on rivaroxaban for 6 months. What is the next best step?
A patient with PE has a PaO2 of 55 mmHg on room air and an increased A-a gradient. What is the primary mechanism of hypoxemia in PE?
A patient with PE has a PaO2 of 55 mmHg on room air and an increased A-a gradient. What is the primary mechanism of hypoxemia in PE?
A patient with PE is found to have elevated troponin and BNP with right ventricular dilation on echocardiogram. What is the most appropriate next step?
A patient with PE is found to have elevated troponin and BNP with right ventricular dilation on echocardiogram. What is the most appropriate next step?
A 70-year-old male with congestive heart failure and chronic kidney disease (CKD) develops acute dyspnea and pleuritic chest pain. CT pulmonary angiogram confirms a PE. What is the best choice for acute anticoagulation?
A 70-year-old male with congestive heart failure and chronic kidney disease (CKD) develops acute dyspnea and pleuritic chest pain. CT pulmonary angiogram confirms a PE. What is the best choice for acute anticoagulation?
A 25-year-old woman on oral contraceptive pills presents with pleuritic chest pain and dyspnea. She is hemodynamically stable. A D-dimer is 1200 ng/mL (elevated). What is the next best step?
A 25-year-old woman on oral contraceptive pills presents with pleuritic chest pain and dyspnea. She is hemodynamically stable. A D-dimer is 1200 ng/mL (elevated). What is the next best step?
Which of the following PE presentations is most concerning for high mortality risk?
Which of the following PE presentations is most concerning for high mortality risk?
A patient with low clinical suspicion for PE (Wells score = 1.5) is being evaluated. Which of the following can rule out PE without further testing?
A patient with low clinical suspicion for PE (Wells score = 1.5) is being evaluated. Which of the following can rule out PE without further testing?
A patient with confirmed PE has BP 88/50 mmHg, tachycardia, and elevated troponins. What is the best initial therapy?
A patient with confirmed PE has BP 88/50 mmHg, tachycardia, and elevated troponins. What is the best initial therapy?
Which of the following is the most common ABG finding in a patient with acute PE?
Which of the following is the most common ABG finding in a patient with acute PE?
A 60-year-old patient with a history of DVT presents with recurrent PEs despite being on therapeutic anticoagulation. What is the best next step?
A 60-year-old patient with a history of DVT presents with recurrent PEs despite being on therapeutic anticoagulation. What is the best next step?
A 50-year-old patient with unprovoked PE has completed 6 months of anticoagulation. What is the next step?
A 50-year-old patient with unprovoked PE has completed 6 months of anticoagulation. What is the next step?
A pregnant woman with a suspected PE is unable to undergo CT pulmonary angiography due to contrast allergy. What is the best alternative test?
A pregnant woman with a suspected PE is unable to undergo CT pulmonary angiography due to contrast allergy. What is the best alternative test?
Which of the following is most appropriate for PE prophylaxis in a hospitalized, immobilized patient at high risk for VTE?
Which of the following is most appropriate for PE prophylaxis in a hospitalized, immobilized patient at high risk for VTE?
A patient with suspected PE undergoes a V/Q scan, which is low probability. His clinical Wells score is high (>6). What is the next step?
A patient with suspected PE undergoes a V/Q scan, which is low probability. His clinical Wells score is high (>6). What is the next step?
Which of the following patients should receive systemic thrombolysis for PE?
Which of the following patients should receive systemic thrombolysis for PE?
Flashcards
What is Virchow's Triad?
What is Virchow's Triad?
Stasis, endothelial injury, and hypercoagulable states.
VTE risk factors?
VTE risk factors?
Malignancy, immobilization, surgery, and prior VTE.
Common VTE Path?
Common VTE Path?
LE thrombus, IVC, right ventricle.
Pathophysiology of PE?
Pathophysiology of PE?
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Common PE Symptoms?
Common PE Symptoms?
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PE Physical Findings?
PE Physical Findings?
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Typical ABG in PE?
Typical ABG in PE?
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What does A-a gradient measure?
What does A-a gradient measure?
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Adjunct studies for PE?
Adjunct studies for PE?
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Primary PE studies?
Primary PE studies?
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What is the primary study option to diagnose PE?
What is the primary study option to diagnose PE?
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EKG finding in PE (S1Q3T3)?
EKG finding in PE (S1Q3T3)?
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CXR signs of PE?
CXR signs of PE?
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What is Westermark sign?
What is Westermark sign?
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Describe Hampton's hump:
Describe Hampton's hump:
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How does Duplex aid in diagnosing PE?
How does Duplex aid in diagnosing PE?
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What does the PERC score do?
What does the PERC score do?
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What is Well's score?
What is Well's score?
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Tests for PE diagnosis?
Tests for PE diagnosis?
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D-dimer definition?
D-dimer definition?
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Pulmonary angiography
Pulmonary angiography
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What is MRI/MRA?
What is MRI/MRA?
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Low-risk PE?
Low-risk PE?
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What is submassive PE?
What is submassive PE?
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Signs of massive PE?
Signs of massive PE?
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Treatment for low risk PEs?
Treatment for low risk PEs?
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Treatment for high risk?
Treatment for high risk?
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When use IVC filter?
When use IVC filter?
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Acute PE meds?
Acute PE meds?
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Which drug do you overlap for 5 days?
Which drug do you overlap for 5 days?
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What is tPA usage?
What is tPA usage?
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Who gets thrombolysis?
Who gets thrombolysis?
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PE Tx duration
PE Tx duration
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Embolectomy is used when?
Embolectomy is used when?
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IVC filter?
IVC filter?
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A direct oral anticoagulant
A direct oral anticoagulant
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pregnancy anticoag
pregnancy anticoag
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Vitamin K antagonist
Vitamin K antagonist
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A PE approved Xa inhibitor?
A PE approved Xa inhibitor?
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Praxbind recently
Praxbind recently
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Pregnant PEs
Pregnant PEs
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Cancer pts don't use?
Cancer pts don't use?
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Recurrent VTE?
Recurrent VTE?
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Preventing VTEs?
Preventing VTEs?
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Recurrent VTE despite anticoagulation
Recurrent VTE despite anticoagulation
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Aspirin for orthopedic pt
Aspirin for orthopedic pt
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Virchow's Triad
Virchow's Triad
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Specific VTE Risk Factors
Specific VTE Risk Factors
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PE
PE
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Signs of Leg DVT
Signs of Leg DVT
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RV Gallop
RV Gallop
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Typical ABG Findings in PE
Typical ABG Findings in PE
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A-a Gradient
A-a Gradient
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Normal labs with PE
Normal labs with PE
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Duplex Ultrasound for DVT
Duplex Ultrasound for DVT
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Well's Criteria
Well's Criteria
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CT Pulmonary Angiogram (CTPA)
CT Pulmonary Angiogram (CTPA)
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Westermark Sign
Westermark Sign
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Anticoagulation Options for PE
Anticoagulation Options for PE
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Apixaban
Apixaban
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Warfarin Restrictions
Warfarin Restrictions
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Anticoagulation and Cancer Patients
Anticoagulation and Cancer Patients
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Switch when on anticoagulation
Switch when on anticoagulation
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PE Risk Factors
PE Risk Factors
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ECG: S1Q3T3 Pattern
ECG: S1Q3T3 Pattern
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Anticoagulation for Cancer + PE
Anticoagulation for Cancer + PE
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PE Treatment in Pregnancy
PE Treatment in Pregnancy
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Treatment for Massive PE
Treatment for Massive PE
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PE and Hypoxemia
PE and Hypoxemia
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Severe CKD (GFR <30)
Severe CKD (GFR <30)
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Unprovoked PE Treatment
Unprovoked PE Treatment
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PE Diagnosis in Pregnancy
PE Diagnosis in Pregnancy
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Study Notes
Pulmonary Embolism (PE) Study Notes - Updated
- PE and venous thromboembolism (VTE) are related conditions.
- Inflammation, hypercoagulability, and endothelial injury are common pathophysiology for VTE and atherosclerosis.
Learning Objectives
- Recognize risk factors for deep vein thrombosis (DVT) and pulmonary emboli.
- Define and calculate the A-a gradient and interpret its clinical implications.
- Describe the presentation, physical exam, diagnostic findings, and treatment options for pulmonary emboli.
Pulmonary Embolism Facts
- PE is both overdiagnosed and underdiagnosed.
- PE is the most preventable cause of death in hospitalized patients.
Virchow's Triad
- Virchow's triad is the basis for thrombus formation:
- Stasis
- Endothelial injury
- Hypercoagulable states
Specific Risk Factors
- Malignancy
- Immobilization
- Surgery within the last 3 months, hip and knee replacement surgery, complicated foot and ankle surgery, trauma
- Preexisting respiratory disease
- Prior history of venous thromboembolism (VTE)
- Chronic heart disease, stroke, and thrombophilia
- Inflammatory triggers, such as infection and transfusion, can stimulate erythropoiesis.
- Increased risk in women who are obese, pregnant, or have hypertension
- Heavy cigarette use
- Oral contraceptive pills and hormone replacement therapy
Pathophysiology VTE
- LE Thrombus → Inferior Vena Cava → Right ventricle → Pulmonary Arteries
- Upper extremity VTE is less common.
Pathophysiology
- Emboli can vary in size from microscopic to large enough to occlude major pulmonary artery branches.
- Embolism obstructing flow in the pulmonary arteries increases resistance, increasing blood flow.
- Hormonal substances cause pulmonary vasoconstriction, increasing pulmonary vascular resistance.
- A saddle embolus is a large clot that obstructs both the right and left pulmonary arteries.
- A 50-60% decrease in perfusion can lead to right ventricular (RV) dysfunction.
- Decreased LV preload leads to decreased LV cardiac output, systemic pressure, and right coronary perfusion.
- A major pathologic effect is V/Q mismatch, resulting in "dead space" ventilation in some parts of the lung and overperfusion in others, leading to hypoxemia.
Signs and Symptoms
- Dyspnea (79%) and Tachypnea (57%)
- Pleuritic pain (47%)
- Leg edema, erythema, tenderness, and palpable cord (47%)
- Cough/hemoptysis (43%)
- Other possible findings include tachycardia, RV gallop, loud P2, and prominent jugular "a" waves suggesting RV failure.
- Syncope or sudden death can occur with massive PE.
ABG Findings
- Typical ABG findings include hypoxemia (low PaO2), hypocapnia (low PaCO2), and increased alveolar-arterial oxygen gradient (A-a gradient).
- 15%-20% have normal ABGs. PE commonly presents with hypoxemia and respiratory alkalosis due to hyperventilation.
A-A Gradient
- It measures how effectively oxygen moves from the alveoli into the pulmonary vasculature.
- A-a Gradient = PAO2 – PaO2
- PAO2 is calculated from the alveolar gas equation.
- PaO2 is measured in the arterial blood.
- Normal A-a gradient on room air is 10 to 20 mmHg.
- It is increased in V/Q imbalance, anatomic shunts, and impaired diffusion.
Studies for Evaluation
- Adjunctive studies include ABG's, EKG's (S1Q3T3), CXR's, echocardiograms, Doppler for DVT evaluation, and cardiac enzymes/BNP.
- The S1Q3T3 pattern is associated with PE (Deep S in Lead I, Q in III, Inverted T in III).
- Primary study options include D-Dimer with CT angio, V/Q scan, pulmonary angiography, and MRI/MRA.
- For low PE risk, a D-dimer test can rule out PE.
- An elevated D-dimer indicates the next step is CTPA.
- If CTPA is not feasible, a V/Q scan is an alternative.
CXR Findings
- "WHALE": Westermark Sign, Hampton's Hump, Atelectasis, Lovely (normal), and Effusions
- Westermark sign indicates dilation in arteries/sharp cutoff.
- Hampton's Hump is a pleural based opacity.
- Atelectasis shows collapse.
- Many CXRs are normal.
- Westermark's Sign (pulmonary oligemia) and Hampton's Hump are specific findings for PE on CXR.
Ultrasound
- Duplex scanning with compression can detect thrombus
- Duplex scanning is highly sensitive and specific for diagnosing DVT.
- It looks for loss of flow signal, intravascular defects, or non-collapsing vessels.
Diagnostic Strategies and Testing
PERC Score
- The PERC score is used for low-risk patients to rule out PE if all criteria are negative:
- Age ≥50, HR ≥100, SaO2 on room air <95%, Unilateral leg swelling, Hemoptysis, Surgery or trauma ≤ 4 weeks ago requiring treatment with general anesthesia, Prior PE or DVT, Oral contraceptives, hormone replacement or estrogenic hormones use in males or female patients.
- If PERC is negative, no further testing is needed in low-risk patients.
Modified Well's Criteria
- Clinical symptoms of DVT (leg swelling, pain with palpation) - 3.0 points
- Other diagnosis less likely than pulmonary embolism - 3.0 points
- Heart rate >100 - 1.5 points
- Immobilization (3 days) or surgery in previous four weeks - 1.5 points
- Previous DVT/PE - 1.5 points
- Hemoptysis - 1.0 points
- Malignancy - 1.0 points
Modified Well's Criteria for Probability
- Traditional clinical probability assessment:
- High: >6.0
- Moderate: 2.0 to 6.0
- Low: <2.0
- Simplified clinical probability assessment:
- PE likely: >4.0
- PE unlikely: <4.0
Real World Advice for Diagnosing PE
- If you don’t think of it, you can’t diagnose it.
- It is far safer to over test than to miss it
- Use Decision Rules (Well’s criteria). They have been tested and work.
- You still have to use clinical judgment-remember it is a diagnosis you can’t afford to miss!
Definitions of PE
- Low Risk PE (70%): no markers of adverse prognosis; BP is stable.
- Submassive PE (20-25%): RV dysfunction or myocardial necrosis, without hypotension, indicated by elevated troponin and BNP with right ventricular dilation on echocardiogram.
- Submassive PE (RV Strain) consider catheter-directed thrombolysis.
- Massive PE (5-10%): sustained hypotension, pulselessness, or persistent bradycardia
Risk Stratify the Patient
- Clinical evaluation, anatomic size of PE, RV size/function, cardiac biomarkers are all factors
- Low Risk: Mainly basic Treatment includes only anticoagulation alone
- High Risk: Advanced treatment with lysis/embolectomy + Anticoagulation
Current Acute Anticoagulants in PE
- Unfractionated Heparin. Requires laboratory monitoring (PTT). Administered IV.
- Severe CKD (GFR <30) means UFH is preferred as LMWH is renally cleared.
- Low Molecular Weight Heparins (LMWH): Dalteparin (Fragmin), Enoxaparin (Lovenox). Administered SC. No lab monitoring.
- LMWH is the preferred anticoagulation if the patient is pregnant.
- Factor Xa Inhibitor: Fondaparinux (Arixtra). Administered SC. No lab monitoring.
- Factor Xa Inhibitors: Rivaroxaban (Xarelto), Apixaban (Eliquis). Oral administration. No lab monitoring.
- PE in cancer = DOAC (Preferred Over Warfarin)
Acute Anticoagulation
- Reduces mortality and is the mainstay of treatment, preventing recurrent PE’s
- Initiate early
- If using Warfarin for long-term treatment, start on the same day as LMWH, fondaparinux, or UFH
- Overlap heparin and warfarin for at least 5 days and stop heparin once INR is 2.0-3.0 for at least 24 hours
Advanced VTE Treatment for Massive and Some Submassive PE Patients
- Systemic Thrombolysis with TPA IV 100mg x 2 hours, then Anticoagulation
- Massive PE (Hypotension) is an indication for tPA unless contraindicated.
- Wait 24 hours before giving anticoagulation after that to help the drug to take effect
- Catheter-based reperfusion for PE + anticoagulation
- Surgical embolectomy + anticoagulation
- Thrombolysis is for hypotensive patients due to PE and without increased bleeding risk
- There is a 1-3% risk of intracranial hemorrhage rate
Contraindication to IVC Filter
- Used if there is contraindication to anticoagulation, bleeding, or severe trauma.
- IVC Filter is indicated in patients with PE and contraindication to anticoagulation.
- Recurrent PE on anticoagulation needs consideration for an IVC filter.
Long-Term Oral Anticoagulation
- Non-pregnant patients without severe renal insufficiency should take apixaban, edoxaban, rivaroxaban, or dabigatran preferred.
- Based on trials there is lower bleeding risk, and improved convenience when compared with warfarin.
- There are consideration for if you cannot stop meds and need more long term maintenance, availability, costs, and other conditions
Current Long-Term Oral Anticoagulation Options
- Vitamin K Antagonist (VKA): Warfarin (Coumadin)
- Cost effective
- Requires monitoring with PT/INR due to food/drug interactions that lead to narrow therapeutic window
- Late onset and requires parenteral anticoagulant
- Vitamin K reversal is slow and may require FFP
- Factor Xa Inhibitors (Direct Oral Anticoagulants):
- High cost medications
- Fixed dose with no need for labs
- Fast onset of action
- Short half-life, may use Andexxa agent for reversal of action
- Not ideal for patients that have low creatinine levels, and need high hepatic clearance
- Rivaroxaban (Xarelto) and apixaban (Eliquis) are approved for short term PE with a quick activation window
- Edoxaban (SAVAYSA) is used with parental anti-coagulants for 5-10 days
- Direct Thrombin Inhibitor (Direct Oral Anticoagulant)
- Dabigatran (Pradaxa) is often used for 5-10days.
- High medicine cost
- Does not require laboratories
- Category C for pregnancy
- Praxbind is another approved option for reversibility.
- May lead to Pradaxa reversing and potential rebound.
- Pregnant patients preferred to be on LMWH
- Cancer patients are often given direct oral anticoagulant or LMWH with low action
Duration of long-term therapy
- First PE that is provoked by surgery or transient risk factor or patient with high risk bleeding is often treated with direct anticoagulants 3 months before stopping.
- Unprovoked PE may continue greater than 3 moths and may decide extended (life-long) anticoagulation in certain patients
- if concern for patient bleed then use Rx aspirin after stopping therapy.
- Unprovoked PE needs consideration for lifelong anticoagulation.
Recurrent VTE Despite Anticoagulation
- When this occurs use LMWH rather than oral medication
- If on LMWH, increase dose of the LMWH
VTE Prevention
- Prophylaxis is important in patients that are high risk
- Intermittent pneumatic compression of lower extremities
- Graduated compression stockings
- Anticoagulation with Heparin, LMWH, Fondaparinux, and apixaban
- Aspirin is indicated for low risk procedures
- Hospitalized + VTE Risk = Heparin or LMWH for Prophylaxis
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