Best Case Ever 44 Low Risk Pulmonary Embolism

We work up a lot of patients for pulmonary embolism. Most of them are not very sick. Dr. Salim Rezaie of R.E.B.E.L. EM tells his Best Case Ever of a Low Risk Pulmonary Embolism that begs us to consider a work-up and management plan that we might not otherwise consider. With new CHEST guidelines suggesting that subsegmental pulmonary embolism need not be treated with anticoagulants in every patient, exceptions to the Well's Score and PERC rule to help guide work-ups, the adaptation of outpatient management of pulmonary embolism, and the option of NOACs rather than warfarin for treatment, the management of pulmonary embolism in 2016 has evolved considerably. In which situations would you treat subsegmental pulmonary embolism? How comfortable are you sending patients home with pulmonary embolism? How does the patient's values play into these decisions? Listen to Dr. Rezaie provide an insightlful perspective on these important issues and much more...



Recorded November 2015 and Februrary 2016; Published February 2016 by Anton Helman & Salim Rezaie



This podcast release marks the 5 year anniversary

of The Best Case Ever podcast series!



Which patients with low risk pulmonary embolism do not require anticoagulation?

Soon after we recorded this Best Case Ever, the American College of Chest Physicians came out with their updated guidelines for the treatment of venous thromboembolism disease. One of the key recommendations has to do with the treatment of new isolated subsegmental pulmonary embolism. "In patients with subsegmental PE and no proximal DVT in the legs who have a low risk for recurrent venous thromboembolism, we suggest clinical surveillance over antigoaculation, and those who have a high risk for recurrent venous thromboembolism, we suggest anticoagulation."

So whether you treat or not depends on whether the patient is high or low risk for recurrent or progressive PE. Which patients are considered high risk you may ask?

Patients who are:



* hospitalized or have reduced mobility for another reason

* have active cancer

* have no reversible risk factor for VTE such as recent surgery



They also suggest that patients with low cardiopulmonary reserve or marked symptoms that cannot be attributed to another diagnosis should get anticoagulated.

Their explanation for this recommendation is that true subsegmental PE is likely to come from a small DVT (and so the risk of progressive or recurrent PE is low), and that many of these so-called subsegmental PEs are false positive over-calls by the radiologist.

They do admit the the evidence for their recommendations are not based on high quality RCTs, but I think the take home message is that we don't have to anticoagulate every patient with a PE.







Criteria for outpatient treatment of low risk pulmonary embolism

The following are two different sets of criteria to consider for outpatient management of patients with low risk pulmonary embolism.

Criteria for outpatient treatment of low risk pulmonary embolism: The Simplified PESI Score

The absence of all of the following:

Age > 80 years

History of Cancer

History of chronic cardiopulmonary disease

Heart rate >110

Systolic BP