Venous thromboembolism: diagnosis and management of pulmonary embolism

Abstract

Pulmonary embolism (PE) affects 0.5–1 per 1000 people in the general population each year, and is one of the most common preventable causes of death among hospitalised patients. The clinical diagnosis of PE is unreliable and must be confirmed objectively with ventilation perfusion scanning or computed tomography pulmonary angiography. The diagnosis of PE can be reliably excluded, without the need for diagnostic imaging, if the clinical pretest probability for PE is low and the D‐dimer assay result is negative. The initial treatment of PE is low‐molecular‐weight heparin or unfractionated heparin for at least 5 days, followed by warfarin (target international normalised ratio [INR], 2.0–3.0) for at least 3–6 months. Patients with a high clinical pretest probability of PE should commence treatment immediately while awaiting the results of the diagnostic work‐up. Thrombolysis is indicated for patients with objectively confirmed PE who are haemodynamically unstable. Percutaneous transcatheter or surgical embolectomy may be life‐saving in patients ineligible for, or unresponsive to, thrombolytic therapy. Unresolved issues in the management of venous thromboembolism include the roles of thrombophilia testing, thrombolysis for the treatment of stable PE patients who present with right ventricular dysfunction, and new anticoagulants; and the duration of anticoagulation for first unprovoked venous thromboembolism.

Venous thromboembolism: diagnosis and management of deep venous thrombosis

“…The optimal intensity and duration of warfarin therapy for VTE are discussed in more detail elsewhere; 2 most patients with unprovoked DVT should be treated for at least 6 months (E2), and long‐term LMWH therapy is more effective than warfarin to prevent recurrent VTE in patients with cancer (E2) 31 …”

“…Here we review the risk factors for VTE, the natural history, diagnosis and treatment of DVT, and primary prevention of VTE. The pathophysiology, diagnosis, prognosis, and treatment of PE and unresolved issues in the management of VTE will be addressed in a subsequent article 2 …”

Duration of anticoagulant therapy for venous thromboembolism

“…The sequelae of VTE include death, post‐thrombotic syndrome, chronic pulmonary thromboembolic disease and recurrent VTE. Anticoagulation with an oral vitamin K antagonist (warfarin), overlapped for the first 5–7 days with unfractionated heparin, low‐molecular‐weight heparin or fondaparinux, prevents thrombus progression and reduces the risk of recurrent VTE and death during the acute phase 2 , 3 . When treatment is continued beyond the acute phase, warfarin reduces the risk of recurrent VTE but increases the risk of bleeding and requires frequent laboratory monitoring, which is inconvenient for patients.…”

“…When treatment is continued beyond the acute phase, warfarin reduces the risk of recurrent VTE but increases the risk of bleeding and requires frequent laboratory monitoring, which is inconvenient for patients. Thus, decisions regarding the optimal duration of anticoagulant therapy must balance the increased risk and sequelae of recurrent VTE when warfarin is stopped against the risk of bleeding and the inconvenience of continuing treatment 3 …”

Inappropriate use and interpretation of D-dimer testing in the emergency department: an unexpected adverse effect of meeting the "4-h target"

“…Unfortunately, many clinicians do not appreciate this distinction 8. Once faced with a positive test result, clinicians may find it difficult to ignore the result, especially if an important and potentially fatal diagnosis such as PE is thought to be suggested by the result 9 10…”