Case

Text

Modified Well's Score

How good is it?

• ~20% of people in the "high risk" went on to have PE
• 0.5% of people in the low risk went on to have PE in the next 3 months

Some other clues?

ECG Changes:

-Sinus Tachy ~44% of patients

RV strain pattern ~34%

Non-specific ST changes ~50% of patients

Use of the Well's Score

Diagnosed PE!

thrombosiscanada.ca

X-Ray Images

X-Ray Images

Fleischner sign (enlarged pulmonary artery)

X-Ray Images

X-Ray Images

• sensitivity: ~14%
• specificity: ~92%
• positive predictive value: ~38%
• negative predictive value: ~76%

• sensitivity: ~22%
• specificity: ~82%
• positive predictive value: ~29%
• negative predictive value: ~76%

• sensitivity: ~22%
• specificity: ~82%
• positive predictive value: ~29%
• negative predictive value: ~76%

Hampton's Hump

Can this patient go home?

PESI Model

PESI Risk Model

Text

Am J Respir Crit Care Med. 2005 Oct 15; 172(8): 1041–1046.

PESI Risk - Mortality

Class I - II can go home if no other factors would keep them in hospital

Duration of Treatment 

• Transient risk factor within 3 months of being dx: 3- 6 months
  • surgery;
  • hospitalization;
  • plaster cast immobilization;
  • hormonal therapy;
  • pregnancy;
  • flight of > 8 hours;
  • recent leg injury;
  • medical illness with immobilization.

Patients with provided VTE: 

• At least 3 months
• 1st unprovoked DVT or PE:
  • 10% recurrence in 1st year, 30% in 5 years and 50% in 10 years

Patients with Persistent Risk Facts - Indefinite anticoagulation

• Active cancer
• Antiphospholipid Ab +
• High risk anti-thrombin

Thrombosis Canada

But why did they get a PE?

- CBC, Ca, LFTs, U/a

- Do NOT do routine thrombophilia testing

Indicated for: VTE < 50 yo, unusual site, during pregnancy, while on e-OCP, FHx VTE < 50 yo

-Age related Cancer Screening

Thrombophilia Work-up

• Factor V Leiden mutation
  • Activated protein C resistance assay
• Prothrombin G20210A mutation
• Protein S deficiency
• Lupus anticoagulant 
• Anticardiolipin