You had a PEnow what? Wissam Jaber, MD Associate Professor of - - PowerPoint PPT Presentation

You had a PE…now what?

Wissam Jaber, MD Associate Professor of Medicine Director, Cardiac Cath Lab Emory University Hospital, Atlanta May 2019

Disclosures

• I have received research funds and consultation fees from Inari

Medical

• I have received consultation fees from Angiodynamic

PE Clinic

Outcome and Prognosis

Early period (first 2 weeks): death and recurrent PE. Depends on:

• presentation (massive, submassive, subsegmental)
• Comorbidities

Late period (3 months or more):

• death mostly related to comorbidities (cancer, age, COPD, CHF)
• Recurrent PE
• CTEPH
• Functional limitation without pulmonary hypertension

Cumulative VTE Recurrence Cumulative Bleeding Risk

Am J Hematol. 2012 May;87 Suppl 1:S63-7

Cumulative incidence of first venous thromboembolism recurrence (—), and the hazard of first recurrence per 1000 person-days (- - -)

Risk Factors

• Ideopathic VTE
• Malignancy
• Age
• Neurologic disease

with leg pareses

Am J Hematol. 2012 May;87 Suppl 1:S63-7

Risk of CTEPH after PE

Risk factors:

• unprovoked PE
• diagnostic delay

>2 weeks

• RV dysfunction
• Previous PE

N Engl J Med. 2004;350(22):2257

• Klok. Blood Reviews 28 (2014): 221-226

High incidence of Functional Limitations after PE

Things to monitor for in follow up

• Anticoagulation
• Bleeding risk
• Recurrence
• Progressive dyspnea/CTEPH, and need for appropriate testing
• The need for IVC filter removal
• Assess risk of recurrence and duration of anticoagulation
• ?Thrombophilia testing

Transition of Care Plan

Follow-Up Algorithm

Persistent Symptoms? (dyspnea, fatigue, lightheadedness, edema)

Consider:

• Anticoagulation: Type, Dose, Duration, Compliance, and Tolerance
• IVC Filter Removal
• Thrombophilia Work Up
• Age-Appropriate Cancer Screening (as indicated)

Follow Up 2 Weeks to 3 Months After Acute PE

RV Abnormal at PE Diagnosis?

TTE, 6MWT, Consider V/Q Scan and/or CPET No Further Follow Up Evaluate for other causes of dyspnea Consider Referral for CTEPH Evaluation

YES NO If All NORMAL If Any ABNORMAL YES NO

Acute PE Follow-Up

Fig 4

Persistent Symptoms? (dyspnea, fatigue, lightheadedness, edema)

• RV Abnormal

at PE Diagnosis?

TTE, 6MWT, Consider V/Q Scan and/or CPET No Further Follow Up Evaluate for other causes of dyspnea Consider Referral for CTEPH Evaluation

YES NO If All NORMAL If Any ABNORMAL YES NO

Fig 4

How well do we follow up on patients?

Disease monitoring in the 2-year period following incident PE

Tapson, et al. Am J of Med. 2016 Sep;129(9):978

Thrombophilia testing

• Identification of high risk thrombophilias:
• APLA, homozygous FVL, and combination defects
• Potential to inform family members
• Important to remember that family history of thrombosis even in

the absence of a specific thrombophilia carries an increased risk of VTE in first degree relatives

• None of these inherited thrombophilias would lead to the use of

primary prevention with anticoagulation outside of high-risk situations

• NOT in the acute setting
• Most of the time it is not needed even at follow up

LENGTH OF ANTICOAGULATION

Bleeding Venous thromboembolism (VTE)

Patient preference

LENGTH OF ANTICOAGULATION

• First Provoked: 3 months
• Recurrent provoked: 3 months with prophylaxis

around high risk situations

• Recurrent unprovoked: Indefinite with periodic

reassessment of bleeding risk

Antithrombotic therapy for VTE. Chest Guidelines Uptade 2016

Presence of high- risk thrombophilia Consider : Prediction rules

Gender D-dimer Age Obesity Mobility Cancer

Patient preference

First unprovoked VTE Low or moderate bleeding risk Extended duration (Grade 2B) High bleeding risk 3 months (Grade 1B)

Adapted from Antithormbotic therapy for VTE. Chest Guidelines Uptade 2016

Thank you