Background: The care of venous thromboembolism (VTE) is currently undergoing a paradigm shift in the US with an increasingly large percentage of patients being discharged home from the Emergency Department (ED). It wasn’t too long ago that all patients diagnosed with deep vein thrombosis (DVT) and pulmonary embolism (PE) would be admitted for anticoagulation. Some of the reasons for this were lack of literature to support outpatient therapy in the US, inability to arrange outpatient follow up, and, of course, medicolegal concerns. Dr. Jeff Kline, one of the thought leaders in VTE, advocates for the outpatient treatment of “low-risk” patients using a modified Hestia criteria supplemented with additional criteria (POMPE-C) for patients with active cancer. This publication is the initial results of his rivaroxaban-based treatment protocol. Read more →
Tag Archive for: PE
Welcome to the September 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Venous Thromboembolism (VTE). Seems like we are hearing more and more about VTE in terms of workup, management, etc. Lets face it, diagnosing someone with a pulmonary embolism (PE) is no longer as simple as checking a d-dimer or just doing a CT Pulmonary Angiogram. There is so much more to it and to frustrate physicians even more there is so much research coming out on this topic alone, even I am having a hard time keeping up. Swami, Matt, and I thought it might be good to tackle a couple of articles from he world of VTE that have implications for clinical practice and patient care. So with that introduction today we are going to specifically tackle:
- Topic #1: Home Treatment of Low Risk Venous Thromboembolism with Rivaroxaban
- Topic #2: RV Dilation on Bedside Echo Performed by ED Physicians
D-dimer has been shown to increase with age, which can cause a lower specificity (i.e. more false positive tests) in older patients. The result of this would be that older patients would often have more diagnostic imaging or downstream testing, but on the other hand, maybe a higher cut-off d-dimer value may lead to increased false negative cases (i.e. missed venothromboembolism) and make this strategy less safe. Recently, I wrote a post on age-adjusted d-dimer testing on REBEL EM, but since that post there was a new article that was published in Chest 2014. This post, will specifically focus on an update of age-adjusted d-dimer testing based on the above article. Read more →
Typically, the treatment of acute pulmonary embolism consists of administration of unfractionated heparin or low molecular weight heparin (i.e. enoxaparin) overlapped with vitamin K antagonists (i.e. warfarin). This can be a very effective treatment regimen, but also very complex. New direct Xa inhibitors are being used more and more in clinical practice with prevention of venothromboembolism (EINSTEIN-DVT Trial), after major orthopedic surgery (RECORD1 Trial), prevention of stroke in patents with atrial fibrillation (ROCKET-AF Trial) , and in the treatment of acute coronary syndromes. Recently, the EINSTEIN-PE Trial evaluated oral rivaroxaban for treatment of symptomatic pulmonary embolism. Read more →
D-dimer testing is sensitive for thrombus formation, and in patients who are not high risk, this test is used to rule-out venous thromboembolism. D-dimer has been shown to increase with age, which can cause a lower specificity (i.e. more false positive tests) in older patients. Specificity can range from 49 – 67% in patients ≤ 50 years of age, but in older patients (i.e. ≥ 80 years of age) the specificity is quoted as 0 – 18%. The result of this is, older patients often have more diagnostic imaging, but a higher cut-off may lead to increased false negative cases (i.e. missed VTE) and make this strategy less safe. So could age adjusted d-dimer testing increase specificity without affecting sensitivity?