Strayerisms - PE My Way

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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Christopher B. -

I really enjoyed this segment. I have two further thoughts I'd like to share.

Patients with subtherapeutic INRs presenting with complaints concerning for PE, e,g, chest pain or dyspnea, may need definitive testing in the case of diagnostic uncertainty. A CTPA showing a recurrent PE may obviate the need for further testing for alternative causes of symptoms (namely ACS).

Agreed, the risk of warfarin failure for PE with a therapeutic INR is low. Two groups of patients seem to be at higher risk though: patients with cancer (should be preferentially treated with LMWH http://www.nejm.org/doi/full/10.1056/NEJMoa025313) and patients with thrombophilias (especially APLAS http://www.nejm.org/doi/full/10.1056/NEJMoa035241).

Reuben Strayer (@emupdates) -

thanks for your comment Chris. certainly, anticoagulated patients who present with chest pain, dyspnea, syncope, or other symptom that may be caused by PE require a thoughtful consideration of the dddx (dangerous differential diagnosis) and if CT chest or any other test is indicated to address that differential, carry on. it's worth noting however that in a patient with a history of PE who is supposed to be anticoagulated, whether or not he actually is anticoagulated, a CTPA positive for PE may or may not explain his new symptoms. for example, if a guy who is supposed to be on warfarin but isn't presents with chest pain, and the CTPA shows a PE, that PE may or may not be the cause of his chest pain, i.e. having a PE doesn't protect you against ACS.

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