Interesting Case - Recurrent PE

Todd Fraser on 12-08-2013

Here's another fascinating case to mull over, sent to me from New Zealand this week.

An 85 year old lady, who had been quite well until 5 years ago, is admitted to a small emergency department with sudden, severe shortness of breath. She has saturations of 92% on 15L oxygen via a non-rebreather, and has a blood pressure of 85/45mmHg. Her blood gas shows a respiratory alkalosis, a big A-a gradient and a base excess of -3mmol/L. Clinically, she has overt right ventricular failure.

This young lass had a history of unprovoked PEs starting 5 years ago, and had suffered 2 further multiple territory PEs in recent years, all associated with stopping her warfarin for minor procedures. Multiple echos have shown her to have severe right ventricular dysfunction and raised pulmonary artery pressures, presumably associated with her PEs. She also has bronchiectasis, basal fibrosis and ischaemic left ventricular dysfunction after an anterior STEMI 12 months ago - an LAD stent was placed at this time.

This latest event occurs in the context of stopping warfarin 6 days ago for the excision of a facial basal cell carcinoma. Her warfarin has just been restarted, but she was not on bridging heparin.

Her CTPA shows pulmonary emboli, but on review of the previous scans, look very similar to previous events. Some minor new PEs are noted in distal branches.

The questions is raised - would you thrombolyse her?

9 Comments

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Shane from Australia wrote 08-14-2013 09:40:10 am
The case for thrombolysis isn't clear - given her comorbidities and her age, the benefit you'd expect is pretty low, and the risks of harm are pretty high. If you can't see a fresh clot there, I guess it could be a PE (as she hasn't got a lot of reserve by the sounds of things), but thrombolysis is a big risk to take for probably minimal benefit.

An old boss of mine used to say "if something's going to go wrong, let nature take the blame" - a modern interpretation of Prima non nocere!

Angie from Australia wrote 08-18-2013 08:10:01 am
I don't really see what you've got to lose. If she has got a a little clot that is making so much difference to her, then its worth a try. Remember her odds of carking it are pretty high if she's hypoxic and hypotensive, even if its due to a little clot.

Shane from Australia wrote 08-21-2013 10:21:19 am
I still think that with little potential benefit you're going to feel pretty crappy if the patient has an intracerebral bleed...

Franno from Australia wrote 08-28-2013 11:42:14 pm
Assuming that she can make her own decisions, our role would be to let her know what we think is going on (very likely a PE, given the profound hypoxia and reap alkalosis), and then let her own value system dictate whether she gets a risky treatment which might save her life for a little bit longer. I always say "walk a mile in their shoes...but always hand the shoes back, or you'll have a barefoot patient, and two pairs of shoes (with one that doesn't fit you)..."

Paul Davies from Australia wrote 09-24-2013 04:44:04 pm
The thrombolysis data is not from patients with recurrent PE and preexisting right heart failure (as far as I know, happy to be corrected) so to extrapolate benefit is not necessarily valid.

I reckon that some heparin and some right heart TLC are the order of the day here......and tell her not to let anyone stop her warfarin without discussion with the haematologist/cardiologist looking after her procoagulant disorder and pulmonary hypertension.

Aleem from India wrote 10-13-2013 11:21:42 pm
Though pt had recurrence it is better not to thrombolyse as pt has risk of intracranial bleed and the intimal changes have already occurred . She might have ctpah

Sid from Australia wrote 11-19-2013 11:52:30 pm
?? end of life discussions

Rachel from Australia wrote 11-20-2013 10:20:35 am
That's an excellent point Sid. You'd have to wonder with all that background morbidity whether you're going to make much of a difference - and the potential cost is high.

I don't think its as simple as saying "well, if she wants to take the risk". If she does get an ICH, it impacts staff too, and whether or not they go on to thrombolyse the next person.

I don't think this is an easy decision but I can't see much potential benefit here.

GerryCapatos from South Africa wrote 12-08-2013 05:18:42 am
Gerry from South Africa. The standard indications for thrombolysis including hypotention and echo findings of right heart dysfunction are not mentioned Also determining new clot on ctpa is important. D-dimer values can assist and once treatment is initiated D-dimer may help to determine if treatment is successful. LMWH plus warfarin will most likely have the same outcome with lower risk of bleeding. Provided patient remained relatively stable especially haemodynamically LMWH plus warfarin good choise. Consider new agents eg thrombin inhibitor. ,