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Venous thromboembolic diseases: Pulmonary embolism Support for education and learning slide set 2013 NICE clinical guideline 144.

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Presentation on theme: "Venous thromboembolic diseases: Pulmonary embolism Support for education and learning slide set 2013 NICE clinical guideline 144."— Presentation transcript:

1 Venous thromboembolic diseases: Pulmonary embolism Support for education and learning slide set 2013 NICE clinical guideline 144

2 What this presentation covers Background Scope Recommendations Discussion NICE quality standard NICE Evidence Services NICE Pathway Find out more

3 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

4 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 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

5 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

6 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

7 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

8 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 scoretwo-level PE Wells score

9 Diagnostic investigations (2) Two-level PE Wells score PE likelyPE unlikely 1. Offer immediate CTPA1. 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

10 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

11 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

12 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

13 Thrombolytic therapy For patients with PE and haemodynamic instability consider thrombolytic therapy Do not offer to patients with PE and haemodynamic stability

14 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

15 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

16 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

17 Investigations for cancer (1) Offer all patients with unprovoked DVT or PE, who are not known to have cancer : physical examination (guided by patients full history) and chest X-ray and blood tests (full blood count, serum calcium and liver function tests) and urinalysis

18 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

19 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

20 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?

21 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 women. Click here to go to the NICE quality standard for management of venous thromboembolic diseases

22 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

23 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

24 Find out more Visit for:http://guidance.nice.org.uk/CG144 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

25 What do you think? Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice? We value your opinion and are looking for ways to improve our tools. Please complete this short evaluation form.short evaluation form If you are experiencing problems accessing or using this tool, please To open the links in this slide set right click over the link and choose open link

26 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

27 Two-level PE Wells score Clinical featurePoints 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 PE3 Heart rate > 100 beats per minute1.5 Immobilisation more than 3 days/surgery in previous 4 weeks1.5 Previous DVT/PE1.5 Haemoptysis1 Malignancy (on treatment/treated in the past 6 months/palliative)1 Clinical probability simplified scores PE likelyMore than 4 PE unlikely4 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 models utility with the SimpliRED D-dimer. Thrombosis and Haemostasis 83: 416–20 Return to slide 8 Diagnostic investigations (1)


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