Pulmonary Embolism Diagnosis & Treatment Guideline .
Pulmonary Embolism Diagnosis & Treatment GuidelineChanges as of September 2020 . 2Background . 2Evaluation and DiagnosisNon-pregnant adults . 4Pregnant adults . 5Adults with cancer. 6Choice of Treatment Setting . 7Subsegmental PE: Treatment Versus Surveillance . 9Treatment with Anticoagulation Medications . 10Recommended testing . 10Choice of anticoagulant medications by population . 10Dosing of anticoagulant medications . 12Duration of anticoagulant medications . 13Follow-up and Monitoring . 13Evidence Summary . 16References . 23Guideline Development Process and Team . 26Appendix 1: Shared decision-making for choosing anticoagulant medication . 27Last guideline approval: September 2020Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health care forspecific clinical conditions. While guidelines are useful aids to assist providers in determining appropriate practices for manypatients with specific clinical problems or prevention issues, guidelines are not meant to replace the clinical judgment of theindividual provider or establish a standard of care. The recommendations contained in the guidelines may not be appropriate foruse in all circumstances. The inclusion of a recommendation in a guideline does not imply coverage. A decision to adopt anyparticular recommendation must be made by the provider in light of the circumstances presented by the individual patient.This evidence-based guideline was developed by Kaiser Permanente Washington (KPWA). 2017 Kaiser Foundation Health Plan of Washington. All rights reserved.1
Changes as of September 2020This 2020 guideline update has only minor differences from the previous (2017) version. The changes are based on the2019 European Society of Cardiology (ESC) Guidelines on the Diagnosis and Management of Acute PulmonaryEmbolism, and include recommendations for the expanded use of direct oral anticoagulants (DOACs) for patients withcancer, recommendations to treat subsegmental and incidental PE in patients with cancer, and options for reduced dosingof DOACs for long-term use for all patients with PE.BackgroundPulmonary embolism (PE) is a relatively common vascular disease with potentially life-threatening complications inthe short term. The accurate incidence of the condition is unknown, but it is estimated that 200,000 to 500,000patients are diagnosed with PE each year in the United States. Many of these cases are diagnosed in the emergencydepartment (White 2016).Traditionally, patients with PE are treated in the hospital (usually for 24 hours but up to 5 or 6 days) for initiation ofanticoagulation therapy and monitoring for any clinical deterioration. The introduction of low molecular weight heparin(LMWH) and the non-vitamin K–dependent oral anticoagulants, together with the increased ability to accuratelystratify patients according to their risk of short-term clinical deterioration, have made it potentially feasible and safe tomanage selected low-risk patients in the outpatient setting either entirely or after a short in-hospital observationperiod.The 2016 American College of Chest Physicians Guidelines treatment at home or early discharge over standarddischarge for patients with low-risk PE (2B recommendation). Many physicians still have concerns regarding theoutpatient treatment or early discharge of low-risk PE patients (Singer 2016).The purpose of this guideline is five-fold: Provide an evidence-based approach to the diagnosis and management of acute pulmonary embolism inclinically stable patients. Identify a population of patients newly diagnosed with PE who can be safely managed as outpatients. Provide guidance on the preferred anticoagulant for initial and long-term therapy, including the use of directoral anticoagulants (DOACs). Improve patient safety and health outcomes for patients with PE. Decrease variation in practice in treating PE.Target populationThe recommendations in this guideline apply to clinically stable outpatients who are: Adults 18 years or older (non-pregnant) with suspected PE. Pregnant adults with suspected PE. Adults with malignancy with suspected PE.ExclusionsThis guideline does not apply to: Clinically unstable patients with suspected PE. These patients should go directly to CT pulmonaryangiography. Hospitalized patients. Patients with established deep vein thrombosis (DVT). These patients may be referred to the KPWAAnticoagulation/Anemia Management Service (AMS).Note: While DVT is outside the scope of this guideline, the recommendations for treatmentof pulmonary embolism (see p. 10) can also be applied to patients with DVT.2
Symptoms of pulmonary embolism Pleuritic chest painShortness of DOACsDVTLMWHPEAmerican College of Chest PhysiciansDirect oral anticoagulantsDeep vein thrombosisLow molecular weight heparinPulmonary embolismPERCPESISSPEUFHVTEPulmonary Embolism Rule-out CriteriaPulmonary Embolism Severity IndexSubsegmental pulmonary embolismUnfractionated heparinVenous thromboembolism3
PE Evaluation and Diagnosis:Non-pregnant Adults Without CancerThis algorithm is based on ICSI 2013.Outpatient with suspected pulmonaryembolism, based on symptomsClinicallyunstable?Wells CriteriaEstimate clinical pretest probability of PE: Clinical signs Alternative diagnosis unlikely Heart rate 100 bpm Immobilization previous 4 days Previous DVT/PE Hemoptysis Malignancy (treatment in last 6 months)CT pulmonaryangiographyYESNOWells CriteriaWells score 7Wells scoreWells score 45 or 6OPTIONALPulmonary Embolism RuleOut Criteria (PERC)PE less likely: 4PE likely: 4Begin anticoagulation without delay.Do CT pulmonary angiography to set abaseline should symptoms recur.CT pulmonary angiographyIf contraindicated, do VQ scan.POSITIVE orPERC NOT DONENEGATIVE monary Embolism Rule Out Criteria (PERC)A single positive criterion qualifies as a positiveresult. Patient aged 50 years Pulse rate 100 bpm Pulse oximetry (RA) 95% Unilateral leg swelling Hemoptysis Surgery or trauma within 4 weeks Prior DVT/PE Oral hormone useAge-adjusted D-dimerNEGATIVEPOSITIVENEGATIVEPOSITIVECT pulmonaryangiographyNEGATIVEPE unlikely. Considerother diagnoses.POSITIVEDetermine treatment settingand treat for pulmonaryembolism.Likelihood of venousthromboembolism (VTE)based on D-dimer?UNLIKELYPE/VTE unlikely.Consider otherdiagnoses.LIKELYBilateral lower limbDoppler ultrasoundNEGATIVEPOSITIVEAge-adjusted D-dimerFor age 50, cutoff 500 ng/mLFor age 50, cutoff [age in years] X 10 ng/mLTreat for venousthromboembolism.4
PE Evaluation and Diagnosis:Pregnant AdultsThis algorithm is based on Leung 2012.Pregnant outpatient with suspected pulmonaryembolism (PE), based on symptomsClinicallyunstable?YESCT pulmonary angiographyNOLegsymptoms?YESBilateral lower limbDoppler ultrasoundPOSITIVENEGATIVENOChest X-rayandCT pulmonary angiographyBOTH NEGATIVEPE unlikely. Consider otherdiagnoses.Treat for PE asinpatient.EITHER POSITIVEIf PE, treat for PE as inpatient.If other diagnosis (e.g., pneumonia,pneumothorax, CHF), treat accordingly.5
PE Evaluation and Diagnosis:Adults with CancerThis algorithm is based on NCCN 2016.Outpatient with cancer with suspectedpulmonary embolism (PE), based onsymptomsWells CriteriaWells scoreWells scoreWells CriteriaEstimate clinical pretest probability of PE: Clinical signs Alternative diagnosis unlikely Heart rate 100 bpm Immobilization previous 4 days Previous DVT/PE Hemoptysis Malignancy (treatment in last 6 months)331.51.51.511PE less likely:PE likely: 4Chest X-rayandAge-adjusted D-dimerAge-adjusted D-dimerFor agecutoff 500 ng/mLFor age 50, cutoff [age in years] X 10 ng/mLDiagnostic forother condition(e.g., pneumonia,pneumothorax,CHF)?NOCT pulmonaryangiographyPOSITIVEDetermine treatment settingand treat for PE.NEGATIVEYESTreat accordingly.PE unlikely. Considerother diagnoses.6
PE Treatment: Choice of SettingInpatient setting All pregnant women All patients not meeting ACCP criteria Patients electing inpatient treatment via shareddecision makingOutpatient settingIncluding short-stay observation unit, where available. Patients meeting ACCP criteria and electingoutpatient treatment via shared decision makingPregnant adultsAll pregnant adults with confirmed acute PE should be treated in an inpatient setting.Non-pregnant adults (with or without cancer)KPWA recommends using the American College of Chest Physicians (ACCP) criteria below to determine whichpatients with confirmed acute PE are suitable for outpatient treatment and can be safely discharged from urgent careto home. (Note: For clinics with short-stay observation units, an additional option is to discharge patients to that unitfor shared decision making around choice of treatment setting.)ACCP criteria for outpatient treatment of acute PE Patient is clinically stable with good cardiopulmonary reserve. Patient has no contraindications, such as recent bleeding, severe renal or liver disease, or severethrombocytopenia ( 70,000/mm3). Patient has none of the following: right ventricular dysfunction shown on echocardiogram, or signs of right heartstrain on CTPA, or increased cardiac biomarkers (troponin or brain natriuretic peptide) levels. Patient is expected to be compliant with treatment. Patient feels well enough to be treated at home. Patient has a Pulmonary Embolism Severity Index (PESI) score of 85:Pulmonary Embolism Severity Index (PESI)PredictorPointsAge 1 per yearMale sex 10Heart failure 10Chronic lung disease 10Arterial oxygen saturation 90% 20Pulse 110 beats per minute 20Respiratory rate 30 breaths per minute 20Temperature 36 C/96.8 F 20Cancer 30Systolic blood pressure 100 mm Hg 30Altered mental status 60The PESI is a validated, accurate, easy-to-use tool that can be used at no cost. It can be accessed y-index-pesi/Risk classification based on PESI scoreRiskClass I: Very low riskClass II: Low riskClass III: Intermediate riskClass IV: High riskClass V: Very high riskPESIscore30-daymortality 6566–850.1 to 1.6%1.7 to 3.5%86–105106–125 1253.2 to 7.1%4.0 to 11.4%10.0 to 24.5%RecommendationOffer outpatient treatment topatients in Classes I and II. Discussthe benefits and risks of outpatienttreatment.Provide inpatient treatment forpatients in Classes III–V.7
Outpatient treatment of PE: eligibility and shared decision-makingOutpatient treatment is recommended only for Class I or II patients who have a good understanding of the risks andbenefits as well as adequate social support. Studies show that patients with Class I and II PESI scores have similarclinical outcomes when treated with warfarin as either outpatients or inpatients.All patients eligible for outpatient care should receive shared decision making about care setting (inpatient versusoutpatient) and choice of anticoagulant (warfarin versus DOAC). Patients should receive appropriate education basedon their choices.The following SmartPhrase—.petreatment—is available in KP HealthConnect (Epic) to support and document theshared decision making process:.petreatmentWe talked about medication and treatment options for your pulmonary embolism. Wereviewed the risks and benefits of the medications, and talked about the advantagesand disadvantages of outpatient treatment.You agreed to understanding the risks and benefits and have decided to do {NEWLIST: outpatient/inpatient} treatment.Here’s a summary of what we talked about for treatment during your visit:Advantages and disadvantages of outpatient treatmentAdvantages: No or less time in the hospital More mobility Lower cost (avoiding co-paysand out-of-pocket expensesassociated with inpatient care) More comfortable in own homeDisadvantages: Concern if something happens thatrequires immediate medical care Possible need for routine lab andblood tests Possible health problems ifmedication is not taken asprescribedAdditional points to consider when discussing treatment setting with the patient: Advantage: Avoiding a hospital stay lowers the risk of hospital-acquired infections or injuries. Disadvantage: Possible discomfort with using medications that are administered by self-injection. Disadvantage: Potential noncompliance with treatment or lack of reliable follow-up.8
Subsegmental and Incidental PE: Treatment Versus SurveillanceThere is no high-quality evidence to support a recommendation for or against anticoagulation treatment versus clinicalsurveillance for patients with subsegmental pulmonary embolism. CHEST (2016) recommends considering factorssuch as hospitalization, reduced mobility, risk factors for VTE (e.g., familial), cardiopulmonary reserve, bleeding risk,and patient preference.In patients with subsegmental PE (PE with no involvement of more proximal pulmonary arteries) and no proximal DVTin the legs, CHEST suggests: Clinical surveillance over anticoagulation for those with a low risk of recurrent VTE, and Anticoagulation over clinical surveillance for those with a high risk of recurrent VTE, including patients withcancer.In patients with cancer, an incidental finding of PE on CT of the chest should be treated the same way as symptomaticPE. In patients without cancer, there is insufficient evidence to recommend treatment of incidental PE.9
PE Treatment: Anticoagulant MedicationsNote: Treatment recommendations apply to both PE and DVT.Testing prior to choosing and initiating anticoagulant medicationsTable 1. Testing recommended prior to choosing and initiating anticoagulant medicationsTest(s)Looking for:Interpretation/considerationsComplete blood count(hemoglobin/hematocrit,platelets, and whiteblood cells [WBC])Myeloproliferativedisorder (e.g.,polycythemia vera,essentialthrombocythemia)Elevations in hematocrit or platelet count, especiallyin patients with splenomegaly, should lead toconsideration of myeloproliferative disorders. Thesedisorders predispose patients to venous and arterialthrombotic events, particularly when theabnormalities are not controlled by therapy.Occult neoplasmSecondary polycythemia or reactive thrombocytosismay suggest underlying malignancy.Paroxysmal nocturnalhemoglobinuriaAnemia, leukopenia, and thrombocytopenia areoften found in paroxysmal nocturnal hemoglobinuria.Partial thromboplastintime (PTT)AntiphospholipidsyndromeIf PTT results are abnormal, screen forantiphospholipid antibodies (e.g., anticardiolipinantibody and lupus anticoagulant).Creatinine/eGFRChronic kidney diseaseDo not use LMWH or fondaparinux in patients withrenal failure (estimated glomerular filtration rate[eGFR] 30 mL/min/1.73 m2 or creatinine clearance 30 mL/min).Prothrombin time/international normalizedratio (PT/INR)Purpose is to establish baseline before initiating anticoagulation.Medication options by populationTable 2. Anticoagulant medication options by populationPopulationGeneral adultpopulationWarfarinYesGiven concurrentlywith LMWH for first 5days until twoconsecutive INR testresults between 2.0and 3.0.Low molecular weightheparin (LMWH)Only ifcontraindications towarfarin and DOACs.Direct oral anticoagulants(DOACs) 1YesRivaroxaban 2 (preferred DOAC).Dabigatran, preceded by at least 5days of LMWH.Pregnant adultsNo 3YesNo 4Adults with cancerNoYesYes 512345Additional DOACs are available; contact Pharmacy for more information. DOACs are contraindicated forpatients with mechanical heart valves.Prior authorization required.Warfarin can be started immediately post-delivery.DOAC can be started immediately post-delivery if not breastfeeding.Rivaroxaban may be prescribed as an alternative to heparin for patients with most cancers, with theexception of gastrointestinal cancer (due to the increased risk of bleeding). In patients with PE related togastrointestinal cancer, apixaban (nonformulary DOAC) can be considered.10
Warfarin Versus DOACsComparison: warfarin versus DOACsWarfarin (Coumadin)DOACsYears on marketIn use for many years.Known long-term side effects.Most common anticoagulant.Relatively new.Research lacking on Long-term side effects, and Relative effectiveness of one DOACagainst another.DosingTaken once a day in the evening. Taken one or two times per day.Dose might change based on lab Dose might change based on lab testtest results.results.Lab tests/monitoringProtime/INR blood tests asneeded to maintain targetrange.Annual labs (CrCl, CBC, LFTs).If indicated, CrCl may be repeatedquarterly.DietRequires consistent intake offoods containing vitamin K.No specific dietary restrictions.Drug interactionsInteracts with many drugs.Fewer drug interactions.DOACs should be avoided with P-gpinducers and 3A4 inducers such ascarbamazepine and phenytoin.Intervention to stopdangerous bleedingVitamin K.General measures to control bleeding canbe used.Reversal agents are available on alimited basis.CostLow cost, generic available.More expensive, no generic available.AspirinFor patients who are unable or unwilling to use warfarin, heparin, or DOACs, aspirin may be considered for longterm anticoagulation.11
Anticoagulant medication dosing for pulmonary embolismTable 3. Anticoagulant medication dosing for pulmonary embolismPopulationGeneral adultpopulation 1“Line”1stDrugWarfarinIn patients likely to be warfarin-sensitive, 2 5 mg initial dose; in patientswithout sensitivity, 10 mg daily x 2 doses; then dose per AMS.andConcurrent low molecular weight heparin (LMWH) for minimum 5 days:Enoxaparin 3 – 1 mg/kg every 12 hours.orDalteparin NF – 200 IU/kg/day once daily.orFondaparinux PAIf heparin-induced thrombocytopenia (HIT): 50 kg: 5 mg once daily50–100 kg: 7.5 mg once daily 100 kg: 10 mg once dailyandTwo consecutive INR test results between 2.0 and 3.0.orPregnantadults 6Adults withcancer1stRivaroxaban PA 4 – 15 mg twice daily with food x 21 days, then20 mg daily with food. Consider reducing dose to 10 mg once daily after 6months of treatment.2ndDabigatran 4,5 – 150 mg twice daily Must be preceded by at least 5 daysLMWH.1stLow molecular weight heparin
PE Evaluation and Diagnosis: Adults with Cancer This algorithm is based on NCCN 2016. Outpatient with cancer with suspected pulmonary embolism (PE), based on symptoms Chest X -ray and Age -adjusted D -dimer Wells Criteria NEGATIVE Determine treatment setting and treat for PE. CT pulmonary angiography PE unlikely. Consider other diagnoses .
diagnosis allows supportive therapy and possible anticoagulation (in some cases, to be started before the conclusion of surgery). . Pulmonary embolism: review of a pathophysiologic approach to the golden hour of a hemodynamically significant pulmonary embolism. Chest 2002;121:877-905 [1], with permission. .
Pulmonary embolism: Surveillance is key LEARNING OBJECTIVES 1. Describe risk factors for and how patients might present with pulmonary embolism (PE). 2. Discuss nursing implications to consider when caring for patients with suspected or confirmed PE. 3. Identify medication management options and associated safety concerns for patients with PE.
ICD-10 Diagnosis Code ICD10 Diagnosis Code Description . Bilateral H628X1 Other Disorders of Right External Ear in Diseases Classified Elsewhere . I2601 Septic Pulmonary Embolism with Acute Cor Pulmonale I2690 Septic Pulmonary Embolism
CTA Chest (pulmonary angiogram) Indication: Evaluate for pulmonary embolism (chest pain, shortness of breath, elevated D-dimer, etc.) Patient Position: Supine, feet down with arms above head Scan Range (CC z-axis): Lung apices to L1 (s
Apr 16, 2019 · treatment, illustrating the public health relevance of the study. v . discharges with a principal diagnosis of pulmonary embolism or proximal deep vein thrombosis; with a secondary diagnosis of pulmonary embolism or proximal deep vein . Magee-Womens Hospital spent 483,936.00 on
presentations are due to pulmonary embolism (PE) and the remainder are due to deep venous thrombosis (DVT) (see DVT: Diagnosis and DVT: Treatment guides). The incidence of PE has increased significantly since the advent of computed tomography (CT) angiography due to its widespread availability and diagnostic sensitivity.
Pulmonary hypertension mean pulmonary artery pressure (mPAP) 25 mmHg at rest 8 Key Ppa mean pulmonary arterial pressure Ppv mean pulmonary venous pressure CO right-sided cardiac output PVR pulmonary vascular resistance. 3/4/2016 3 Pathophysiology Ppa (CO x PVR) PCWP 9
menentukan kadar asam folat. Fortifikan yang ditambahakan asam folat sebanyak 1100 mcg/100 gr bahan dan Fe-fumarat 43.4 mg/100 gr bahan. Dari hasil penelitian didapatkan hasil kadar asam folat pada adonan sebesar 1078,51 mcg/100 gr, pada pemanggangan I sebesar 1067,97 mcg/100 gr,
