Transcript Document

Venous thromboembolic diseases:
Pulmonary embolism
Support for education and learning slide set
2013
NICE clinical guideline 144
What this presentation covers
• Background
• Scope
• Recommendations
• Discussion
• NICE quality standard
• NICE Evidence Services
• NICE Pathway
• Find out more
Glossary
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INR: International normalised ratio
VTE: Venous thromboembolism
PE: Pulmonary embolism
DVT: Deep vein thrombosis
CTPA: CT pulmonary angiogram
V/Q SPECT: Ventilation perfusion scan
PTS: Post-thrombotic syndrome
VKA: Vitamin K antagonist
UFH: Unfractionated heparin
LMWH: Low molecular weight heparin
Definitions
• Provoked DVT or PE: DVT or PE in patients with recent
occurrence of major clinical risk factor for VTE
• Proximal DVT: DVT in popliteal vein or above
• Renal impairment: eGFR of less than
90 ml/minute/1.73 m2 (see notes)
• Unprovoked DVT or PE: DVT or PE in patients with no
recently occurring major clinical risk factors for VTE or
patients with active cancer, thrombophilia or family
history of DVT (these are risks, but they are constant)
• Wells score: clinical prediction rules for estimating
probability of DVT and PE
Background
• Thrombus (blood clot) forms in a vein
• Deep vein thrombosis - in deep veins of leg or pelvis
• Pulmonary embolism - thrombus dislodges and
travels to pulmonary arteries
• Term ‘venous thromboembolism’ includes DVT and
PE
• Risk factors include: thrombophilia, history of DVT,
surgery, obesity, acute illness, cancer and immobility
• 500,000 people in Europe die from preventable
hospital-acquired VTE every year
Scope
• Guidance on management of VTE, investigations for
cancer in patients with VTE and thrombophilia testing
• Covers adults with suspected or confirmed DVT or PE
• Includes advice on the Wells score, D-dimer
measurement, ultrasound and radiological imaging
• Does not cover those younger than 18, or women
who are pregnant
Recommendations for PE
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Diagnostic investigations and diagnosis
Treatments
– pharmacological interventions
– thrombolytic therapy
– mechanical interventions
• Patient information
– verbal and written
– self-management
• Investigations for cancer
• Thrombophilia testing
Diagnostic investigations (1)
In patients presenting with signs or symptoms of PE, carry
out the following to exclude other causes:
• an assessment of their general medical history
• a physical examination and
• a chest X-ray
If PE suspected use the two-level PE Wells score
Diagnostic investigations (2)
Two-level PE Wells score
PE likely
PE unlikely
1. Offer immediate CTPA
1. Offer a D-dimer test
2. If CTPA not immediately
available offer interim
parenteral anticoagulant
therapy followed by CTPA
2. If D-dimer positive offer
immediate CTPA
3. If CTPA negative and DVT
suspected consider proximal
leg vein ultrasound
3. If CTPA not immediately
available offer interim
parenteral anticoagulant
therapy followed by CTPA
Diagnosis
Diagnose PE and start treatment if positive CTPA or if PE
identified with V/Q SPECT or planar scan
Consider alternative diagnoses in patient with:
• unlikely two-level PE Wells score and:
– negative D-dimer test or
– positive D-dimer test and negative CTPA
• likely two-level PE Wells score and:
– negative CTPA and
– no suspected DVT
Pharmacological interventions (1)
Confirmed PE or proximal DVT
Offer low molecular weight heparin (LMWH) or
fondaparinux as soon as possible, unless:
• severe renal impairment
• increased risk of bleeding
• haemodynamically unstable
Confirmed PE or proximal DVT and active cancer
Offer LMWH, continue for 6 months
Pharmacological interventions (2)
Patients with confirmed PE or proximal DVT
• Offer a VKA to patients with confirmed proximal DVT
or PE within 24 hours of diagnosis and continue the
VKA for at least 3 months
Thrombolytic therapy
For patients with PE and haemodynamic instability
consider thrombolytic therapy
Do not offer to patients with PE and
haemodynamic stability
Mechanical interventions
Temporary inferior vena caval filters:
• offer to patients with proximal DVT or PE who cannot
have anticoagulation treatment
• consider for patients with recurrent proximal DVT or
PE despite adequate anticoagulation treatment (after
considering alternatives)
Ensure strategy for removing filter at earliest possible
opportunity is planned and documented when filter is
placed
Patient information:
verbal and written
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How to use anticoagulants
Duration of treatment
Possible side effects and what to do
Effects of other drugs, foods and alcohol
Monitoring
How anticoagulants may affect dental treatment
Taking anticoagulants if they are planning pregnancy
or become pregnant
• How activities may be affected
• When and how to seek medical help
Patient information:
self-management
Information and advice
• Anticoagulant information booklet
• Anticoagulant alert card
• Heparins of animal origin may be of concern to some
patients
Self monitoring of INR
• Do not routinely offer to PE or DVT patients
Investigations for cancer (1)
Offer all patients with unprovoked DVT or PE, who are
not known to have cancer :
• physical examination (guided by patient’s full history)
and
• chest X-ray and
• blood tests (full blood count, serum calcium and liver
function tests) and
• urinalysis
Investigations for cancer (2)
• First unprovoked DVT or PE?
• No signs or symptoms of cancer based on initial
investigation?
• Over 40?
Consider further investigations for cancer:
• abdomino-pelvic CT scan
• mammogram for women
Thrombophilia testing
X Do not offer to patients who are continuing
anticoagulation treatment
X Do not offer to patients who have had provoked DVT or
PE
X Do not routinely offer to first-degree relatives of people
with a history of DVT or PE and thrombophilia
Consider for patients with unprovoked PE or PE if it is
planned to stop anticoagulation treatment
Discussion
• If not already common practice, how can we ensure we
are able to offer immediate CTPA to eligible patients?
• Do we have the appropriate systems in place to ensure
patients with a PE receive the appropriate follow up in
order to assess continuation of LMWH and VKA?
• What referral systems do we have in place to facilitate
the onward investigation for cancer and thrombophilia
for patients with unprovoked PE? How do they need
to be modified in order to meet the NICE
recommendations?
NICE quality standard for diagnosis
and management of venous
thromboembolic diseases
• Published March 2013
• Defines clinical best practice within this topic area.
• Provides specific, concise quality statements,
measures and audience descriptors to provide the
public, health and social care professionals,
commissioners and service providers with definitions of
high-quality care.
• Covers the diagnosis and treatment of venous
thromboembolic diseases in
adults, excluding pregnant
Click here to go to the NICE quality
women.
standard for management of
venous thromboembolic diseases
NICE Evidence Services
Visit NICE
Evidence
Services for the
best available
evidence on all
aspects of VTE
diseases
Click here to go to
the NICE Evidence
Services website
NICE Pathway
The NICE VTE Pathway
shows all the
recommendations in the
VTE diseases and
VTE - reducing the risk
guidelines.
Click here to go to
the NICE Pathways
website
Find out more
Visit http://guidance.nice.org.uk/CG144 for:
• the guideline
• information for the public
• costing report
• audit support
• baseline assessment tool
• PE educational resource (training plan, slide set and
clinical case scenarios)
• DVT educational resource (training plan, slide set and
clinical case scenarios)
• podcast
• two-level wells score templates
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Additional slide
The next slide contains the two-level PE Wells score
If you used the hyperlinks to the Wells score during the
presentation you have already visited this slide
Two-level PE Wells score
Clinical feature
Points
Clinical signs and symptoms of DVT (minimum of leg swelling and pain
with palpation of the deep veins)
3
An alternative diagnosis is less likely than PE
3
Heart rate > 100 beats per minute
1.5
Immobilisation more than 3 days/surgery in previous 4 weeks
1.5
Previous DVT/PE
1.5
Haemoptysis
1
Malignancy (on treatment/treated in the past 6 months/palliative)
1
Clinical probability simplified scores
PE likely
PE unlikely
More than 4
4 or less
Adapted with permission from Wells PS et al. (2000) Derivation of a simple clinical model to categorize patients’
probability of pulmonary embolism: increasing the model’s utility with the SimpliRED D-dimer. Thrombosis and
Haemostasis 83: 416–20
a
Return to slide 8
‘Diagnostic investigations (1)’