CT scan through chest showing acute pulmonary embolism with blood clots in right and left pulmonary arteries
emergency, and any delay in treatment increases the risk of mortality. Vigorous resuscitation, thrombolysis and (in most cases) urgent transfer to the intensive care unit are essential. Trombolysis rapidly improves haemodynamic function, and is most effective when administered within hours of the onset of symptoms. In modern practice, pulmonary thrombectomy is usually reserved for patients who have contraindications to thrombolysis such as recent surgery, any bleeding risk or recent stroke. • Treatment of PE in the stable patient and secondary prevention. As soon as the diagnosis is considered likely, LMWH at a full anticoagulant dose should be administered without delay. Under these circumstances, the inevitable delay in arranging CTPA to confirm the diagnosis does not put the patient at risk of further PE. Traditionally, Vitamin K antagonists (usually warfarin) have been prescribed concurrently, with a target INR of 2-3. Once this has been achieved, subcutaneous LMWH can be withdrawn. Novel anticoagulants (predominantly the Factor Xa inhibitors ‘xabans’) are now replacing warfarin as they do not require the same costly and inconvenient monitoring. In most cases, anticoagulation should be continued for 3-6 months to reduce the risk of VTE recurrence. As with all treatments, experienced clinical judgement is
required to assess the individual patient’s risk and benefit, and to advise the patient and their family whether shorter or longer periods of anticoagulation should be considered.
n Mr David Riding is a clinical research fellow at the University
of Manchester n Professor Charles McCollum is Professor of Surgery at the University of Manchester
SUMMER 2016
REFERENCES
1 Huerta, C., Johansson, S., Wallander, M.A. and Garcia Rodriguez, L.A. (2007) Risk factors and short-term mortality of venous thromboembolism diagnosed in the primary care setting in the United Kingdom. Archives of Internal Medicine 167(9):935-943.
2 CEMACH (2007) Saving mothers’ lives: reviewing maternal deaths to make motherhood safer – 2003-2005. Confidential Enquiry into Maternal and Child Health.
3 Meyer, G., Roy, P.M., Gilberg, S. and Perrier, A. (2010) Easily missed? Pulmonary embolism. British Medical Journal 340:c1421.
4 Klok FA, Mos ICM, Nijkeuter M, Righini M, Perrier A, Le Gal G et al. (2008) Simplification of the Revised Geneva Score for assessing clinical probability of pulmonary embolism. Archives of Internal Medicine 168(19):2131-2136.
OTHER SOURCES • National Institute for Health and Care Excellence (2015). Clinical Knowledge Summaries: Pulmonary Embolism.
http://cks.nice.org.uk/ pulmonary-embolism#!topicsummary. Last accessed 18th May 2016. • Brandjes DP, Heijboer H, Buller HR, de Rijk M, Jagt H, ten Cate JW (1992) Acenocoumarol and heparin compared with acenocoumarol alone in the initial treatment of proximal-vein thrombosis. New England Journal of Medicine 327:1485-1489. • Cohen, A.T., Agnelli, G., Anderson, F.A. et al. (2007) Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thrombosis and Haemostasis 98(4):756-764. • Kearon C, Ginsberg JS, Hirsh J. (1998) The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism. Annals of Internal Medicine 129:1044-1049.
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PHOTOGRAPH: PR MICHEL BRAUNER/SCIENCE PHOTO LIBRARY
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