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PE, DVT and VTE prophylaxis Dr. Kevin Dsouza (Clinical fellow )Bedfordshire Hospital NHS trustCONTENTS PE overview DVT overview VTE prophylaxis MCQ quiz + Clinical scenarioVIRCHOW’S TRIAD PULMONARY EMBOLISM Pulmonary embolism (PE) is a life-threatening condition in which one or more emboli, usually arising from a thrombus formed in the veins, are lodged in and obstruct the pulmonary arterial system, causing severe respiratory dysfunction. It can be divided into a) Provoked PE is associated with a recent (within 3 months) and transient major risk factor, such as significant immobility, surgery, trauma, pregnancy or puerperium, or use of hormonal therapy a) Unprovoked PE occurs in the absence of arecent (within 3 months) major clinical risk factor in a person who is not using hormonal therapy. RISK FACTORS Major Risk Factors for PE: ● Deep Vein Thrombosis (DVT): 45-50% of PE cases have DVT. ● Recent Surgery: 29% of PE cases within 2 months post-surgery, especially orthopedic. ● Immobility: Includes hospitalization, paralysis, or bed rest (>5 days). ● Previous VTE: 25% of PE cases have a prior thromboembolism. ● Active Cancer: 22% of PE cases, with higher risk in specific cancers (lung, pancreatic, etc.). Other Risk Factors: ● Pregnancy/Postnatal Period: Risk increases 4-5 fold, especially postpartum. ● Hormonal Therapy: Combined contraceptives and HRT increase VTE risk. ● Obesity, Smoking, Long Travel, Medical Conditions: COPD, heart failure, IBD, nephrotic syndrome, etc. SYMPTOMS ● Dyspnoea (shortness of breath): Most common symptom, present in 50% of cases; can be severe or mild depending on the PE location. ● Haemoptysis ● Pleuritic chest pain ● Syncope or presyncope ● Tachypnoea ● DVT symptoms ● Retrosternal chest pain ● Cough: Other Signs: ● Elevated jugular venous pressure. ● Fever. ● Gallop rhythm, wide split-second heart sound, tricuspid regurgitant murmur. ● Hypotension (systolic BP < 90 mmHg) and cardiogenic shock. ● Hypoxia (low oxygen levels). ● Pleural rub. ● Tachycardia (heart rate > 100 bpm).DIAGNOSIS ECG Chest Xray Bloods including D dimer WELLS score, PESI score (30 day mortality risk) CT Pulmonary Angiogr am (CTPA)TREATMENT ● Pharmacological (Anticoagulation): Fondaparinux, LMWH, warfarin, apixaban, rivaroxaban. ● Mechanical: IVC filters if anticoagulation fails or is contraindicated. ● Thrombolysis: Systemic or catheter- directed (alteplase/reteplase) ● Surgery: Open pulmonary embolectomy. (rarely used) DVT ● Deep vein thrombosis (DVT) is the formation of a thrombus (blood clot) in a deep vein, usually in the legs, which partially or completely obstructs blood flow. These clots may obstruct blood flow either partially or entirely. Although DVTs typically manifest in the lower leg, thigh, or pelvis, they can also arise in other regions, including the arms, brain, intestines, liver, or kidneys. RISK FACTORS Ongoing/Intrinsic: Temporary: ● History of DVT, cancer, age >60, male gender ● Recent surgery, hospitalization, or trauma ● Chemotherapy, immobility, prolonged travel ● Obesity, heart failure, smoking, varicose veins ● Hormone treatments (e.g., contraceptives, ● Inflammatory disorders (e.g., IBD, vasculitis) ● Acquired/familial thrombophilia, acute medical HRT), pregnancy/postpartum illness ● Dehydration COMPLICATIONS 1)PULMONARY EMBOLISM 2)Post-thrombotic syndrome — a chronic venous hypertension causing limb pain, swelling, hyperpigmentation, dermatitis, ulcers, venous gangrene, and lipodermatosclerosis. SIGNS & SYMPTOMS ● Unilateral localized pain (throbbing) with walking or weight- bearing. ● Calf swelling (or full leg swelling in rarer cases). ● Tenderness in the affected area ● Skin changes: oedema, redness, warmth. ● Vein distension. Physical examination and history: ● Rule out alternative causes for symptoms. ● Measure leg and thigh swelling by comparing the circumference 10 cm below the tibial tuberosity with the asymptomatic leg. A difference of >3 cm increases the likelihood of DVT. ● Check for oedema and dilated collateral superficial veins on the affected side. DIAGNOSIS 1) Clinical diagnosis with symptoms 1) Bloods including D dimer 1) Wells score 1) Ultrasound Doppler TREATMENT ANTICOAGULANTS Treatment duration: Typically 3 months; may be longer for unprovoked DVT (no transient risk factor). Things to consider- Thrombophilia testing: Offer to appropriate patients with unprovoked DVT. Compression stockings: Do not offer to prevent post-thrombotic syndrome or recurrence after proximal DVT. VTE PROPHYLAXIS Venous thromboembolism (VTE) prophylaxis consists of pharmacological and non-pharmacological measures to diminish the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE includes both deep-vein thrombosis (DVT) and pulmonary embolism (PE), involving blood clots in veins that obstruct blood flow. Hospital-acquired VTE refers to a VTE occurring within 90 days of hospital admission. Risk assessment for VTE and bleeding should be done upon hospital admission. TYPES OF VTE PROPHYLAXIS AND PATIENTS Mechanical: Anti-embolism stockings or intermittent pneumatic compression. Pharmacological: Start within 14 hours of admission, unless risk of bleeding outweighs. Surgical Patients: Medical Patients: ● Regional anesthesia preferred over general to ● Pharmacological prophylaxis for acutely ill patients reduce VTE risk. at high VTE risk. ● Mechanical prophylaxis (e.g., anti-embolism ● Mechanical methods (e.g., intermittent pneumatic stockings) for major surgeries (trauma, cranial, compression) if pharmacological prophylaxis is abdominal, thoracic, cardiac, spinal). contraindicated (e.g., acute stroke). ● Pharmacological prophylaxis for general and orthopedic surgeries with high VTE risk. Pregnancy- Pregnant women with high VTE risk should receive low molecular weight heparin during hospital admission.DDOAC : Xa1)Which of the below options is NOT a predominant symptom of Pulmonary Embolism (PE)? A) Sudden shortness of breath B) Chest pain C) Hemoptysis (coughing up blood) D) High fever2) Which blood vessels are primarily affected in Pulmonary Embolism (PE)? A) Pulmonary veins B) Coronary arteries C) Pulmonary arteries D) Aorta3)What is the Wells score used for in Pulmonary Embolism (PE)? A) To determine the need for surgery in PE B) To assess the likelihood of PE C) To measure oxygen levels in the blood D) To calculate long-term survival in PE patients4) Which of the following is NOT a anticoagulant? 1) Alteplase 2) Rivaroxaban 3) Heparin 4) TinzaparinClinical Scenario : A 45-year-old man presents to the Emergency Department with complaints of sudden-onset shortness of breath that began the previous night. He reports difficulty sleeping due to breathlessness and describes a vague, non-radiating chest discomfort. He denies any cough, fever, or recent illness. He is generally fit and well with no significant past medical history, no recent surgeries, and no known risk factors for blood clots. He does, however, mention a long-haul flight to Europe one week ago.On examination, he appears anxious and is using accessory muscles to breathe. His vital signs show: ● Oxygen saturation: 93% on 4L nasal cannula ● Respiratory rate: 26 breaths per minute ● Heart rate: 115 bpm (sinus tachycardia on ECG) ● Blood pressure: 100/65 mmHg ● Temperature: 36.8°C You notice mild distension of the jugular veins, and his lungs are clear on auscultation.Investigations: ● ECG ● Chest X-ray ● D-dimer: 650 ( normal 0-250 ng/dl) ● Wells score for PETHANK YOU. ANY QUESTIONS?