24th July 2024

PE

Clinical features of PE

Presentation is typically with dyspnoea, pleuritic chest pain, haemoptysis or collapse. Examination may be normal.

Scoring systems to aid diagnosis and choose investigations include Well’s score for PE and PERC (both can be found online).

Investigations findings may include:

• ECG: the most common finding is sinus tachycardia; there may be evidence of right heart strain such as new onset right bundle branch block; the classical finding of S1Q3T3 can be caused by PE, but is uncommon and not diagnostic
• CXR: unremarkable in the majority of patients, however PEs can cause pleural effusions (normally exudative) or, if severe, can cause pulmonary infarction which can be seen on CXR
• Troponin and BNP: if positive, demonstrate heart strain
• CT pulmonary angiogram (CTPA) is the gold standard test to investigate PE

Management of PE

The vast majority of patients with PE will be anticoagulated, however for those in which this is contraindicated, inferior vena cava (IVC) filters can be considered. Thrombolysis (usually with alteplase) and thrombectomy are considered for patients with haemodynamic compromise.

Aetiology of VTE

Another important consideration when managing VTE is working out the underlying cause. This is important as it will help determine the duration of treatment and change management (e.g. if medication related, the offending agent may have to be stopped). Common causes include: immobility, surgery, combined oral contraceptive pill, malignancy and prothrombotic conditions including inherited. If a VTE is considered to be provoked, then a 3-month duration of anticoagulation is sufficient, however if unprovoked, 6 months of treatment may be indicated.

If a cause is not obvious, further investigations may be warranted. Malignancy is a common cause of VTE, however NICE only recommends investigating for cancer if the history or examination is suggestive.