A 39-year-old man presents to the ED with shortness of breath and tachycardia. He eventually develops hypotension with a systolic blood pressure of 80 mmHg. A stat CT scan of the chest reveals a saddle pulmonary embolism involving the main pulmonary artery trunk.
Which of the following is the next most appropriate step?
Begin alteplase 100 mg IV over 2 hours. The patient presented has a clinically massive pulmonary embolism with hemodynamic compromise; thus thrombolytic therapy is indicated.
Reference:
The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: evidence-based guidelines. Chest Suppl. 2004;126:413S.
Which of the following findings or laboratory values could be used to predict his prognosis?
Atrial arrhythmia. There have been many laboratory, ECG, and echocardiogram findings shown to be predictive of mortality and prognosis. Right ventricular dysfunction, particularly when accompanied by hypotension, is predictive of pulmonary embolism–related hospital mortality. Elevated serum troponin and elevated brain natriuretic peptide have also been shown to predict an increased risk of death. Additional findings associated with a poorer prognosis include atrial arrhythmia, right bundle branch block, inferior Q waves and precordial T-wave inversions, and ST-segment changes. The other distracters have not been shown to predict prognosis.
A 52-year-old man with metastatic prostate cancer has developed left lower extremity swelling. You order an ultrasound and a left acute external iliac deep vein thrombosis is visualized. You hospitalize the patient and his initial labs reveal hemoglobin 14.5 g/dL and creatinine 1.0 mg/dL.
Which of the following treatment options is most appropriate?
Begin enoxaparin 1 mg/kg subcutaneous injections every 12 hours. Cancer patients are at a sixfold increased risk of developing VTE. Patients with active cancer make up about 20% of all new VTE diagnosed in the community. The risk, however, varies somewhat with cancer type, and those that incur a higher risk include malignant brain tumors and adenocarcinoma of the ovary, pancreas, colon, stomach, lung, prostate, and kidney. Several studies have demonstrated a benefit to treatment with LMWH when compared with coumadin in this patient population. One study, which compared dalteparin with coumadin, reported 27 of 336 patients in the LMWH group had recurrent VTE when compared with 53 of 336 in the coumadin group in a 6-month follow-up period. There was no increased risk of bleeding in the LMWH group.
A 55-year-old man is admitted to the hospital with upper gastrointestinal bleeding. He is transfused with 2 units of packed red blood cells and undergoes esophagogastroduodenoscopy. A bleeding gastric ulcer is discovered and treated with epinephrine injection. Several days into his admission he begins complaining of right calf discomfort. Venous duplex ultrasound is performed demonstrating acute deep vein thrombosis of the popliteal and posterior tibial veins.
What is the next appropriate step in the management of this patient?
Proceed with placement of an inferior vena cava filter. The patient has a proximal DVT with a contraindication for anticoagulation. This scenario represents an absolute indication for the placement of an inferior vena cava filter. Pneumatic compression stockings are indicated for the prevention of VTE but not for treatment. Serial duplex ultrasound scans may be an acceptable strategy for management of isolated acute calf vein thrombosis but not for proximal DVT. IV unfractionated heparin or enoxaparin 1 mg/kg subcutaneous injections would be appropriate treatment options if the patient did not have a recent gastrointestinal bleed requiring transfusion.
Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141:e419S–e494S.
A 58-year-old man presents to the clinic with a complaint of bilateral lower extremity cramping muscular pain with exertion relieved after a few minutes of rest. His medical history includes coronary artery disease status post left anterior descending artery stent 2 years ago, diabetes mellitus type 2, and essential hypertension. An ABI is performed in your office demonstrating a right ABI of 1.10 and left ABI of 1.04.
What is the most appropriate next step in the evaluation of this patient?
Order bilateral ABI measurements in the vascular laboratory at rest and following an exercise protocol. The patient in the clinical vignette presented with classic intermittent claudication symptoms suggestive of PAD. A normal resting ABI does not rule out PAD in a patient presenting with ambulatory symptoms. Performing the test following exercise often unmasks significant disease revealing markedly lower ABI values. Exercise may be an appropriate suggestion but it will not help to establish the diagnosis of this patient’s presenting problem. It would be premature to refer this patient for intervention. Pseudoclaudication may present similarly, but this patient has risk factors for PAD; therefore, a post exercise ABI would be the most appropriate next step in their workup. Repeating the resting ABI in 6 months is not likely to provide new information.
Anderson JL, Halperin JL, Albert NM, et al. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:1425–1443.
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