Venous thromboembolic diseases Pulmonary embolism Support for education

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 • • • 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: e. GFR of less than 90 ml/minute/1. 73 m 2 (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 • • 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 • • 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/CG 144 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 a 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 Simpli. RED D-dimer. Thrombosis and Haemostasis 83: 416– 20 Return to slide 8 ‘Diagnostic investigations (1)’