Risk Severity scoring of PE & DVT

1. Risk / Severity scoring
PE & DVT
D R . M D . S H A F I Q U L I S L A M D E WA N
R E S I D E N T ( P U L M O N O L O G Y )
R E S P I R A T O R Y M E D I C I N E D E P A R T M E N T
D H A K A M E D I C A L C O L L E G E H O S P I T A L

2. Venous Thromboembolism(VTE)
Common presentation:
 Deep vein thrombosis (DVT) of the leg
 Pulmonary embolism (PE)
Uncommon presentation:
 Jugular vein thrombosis
 Upper limb DVT
 Cerebral sinus thrombosis
 Intra-abdominal venous thrombosis (e.g. Budd–Chiari syndrome).
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 2

3. Pulmonary Embolism
Majority of pulmonary emboli arise from lower limb deep vein thrombosis.
Rare causes include_
 Septic emboli (from endocarditis affecting the tricuspid or pulmonary valves)
 Tumor (especially choriocarcinoma)
 Fat following fracture of long bones (such as the femur)
 Air and
 Amniotic fluid (which may enter the mother’s circulation following delivery).
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 3

4. Factors predisposing to venous thrombosis
Patient factors
 Increasing age
 Obesity
 Varicose veins
 Previous deep vein thrombosis
 Family history, especially of unprovoked
venous thromboembolism when young.
Transient additional risk factors
 Pregnancy/puerperium
 Estrogen-containing oral contraceptives
and hormone replacement therapy
 Immobility, e.g. long-distance travel (>4
hrs)
 Intravenous drug use involving the
femoral vein
 Surgery (see below)
 Medical illnesses (see below)
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 4

5. Factors predisposing to venous thrombosis
Medical conditions
 Myocardial infarction/heart failure
 Inflammatory conditions: inflammatory
bowel disease, connective tissue
disorders and vasculitis
 Malignancy (anti-cancer chemotherapy
increases the risk of venous
thromboembolism compared with cancer
alone)
 Nephrotic syndrome
 Chronic obstructive pulmonary disease
 Severe infection, bacterial or viral
 Neurological conditions associated with
immobility, e.g. stroke, paraplegia,
 Guillain–Barré syndrome
 Any high-dependency admission
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 5

6. Factors predisposing to venous thrombosis
Surgical conditions
 Major surgery, especially if >30 mins’
duration
 Abdominal or pelvic surgery, especially for
cancer
 Major lower limb orthopedic surgery, e.g.
joint replacement and hip fracture
surgery.
Antiphospholipid syndrome
Hematological disorders
 Polycythaemia rubra vera
 Essential thrombocythaemia
 Deficiency of natural anticoagulants:
antithrombin, protein C, protein S
 Paroxysmal nocturnal haemoglobinuria
 Gain-of-function prothrombotic mutations:
factor V Leiden, prothrombin gene G20210A
 Myelofibrosis
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 6

7. 4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 7

8. Two-Level PE Wells score
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 8

9. 4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 9

10. Pulmonary Embolism Severity Index (PESI)
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 10

11. Management based on PESI
If the patient is considered very low (≤ 65) or low risk (66-85) by the PESI score.
 Patient has an overall low risk of mortality or severe morbidity.
 Consider outpatient management of PE if clinically appropriate and social factors allow for
it.
If the patient is considered intermediate (86-105), high risk (106-125) or very high risk (>125)
by the PESI.
 Patient has an overall high risk of mortality and severe morbidity.
 Consider higher levels of care (e.g., ICU) for those with higher scores.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 11

12. Critical Actions of PESI
The PESI is only meant for risk stratification of pulmonary embolism after the
diagnosis has been made.
Findings which could point toward clinically significant PE should not be
overlooked in the setting of a low PESI score.
Additional pathology which could lead to morbidity or mortality should not be
overlooked in the setting of a low PESI score.
All results for the validation of the PESI were made with patients who were
treated for PE initially with enoxaparin, and then encouraged to transition to
vitamin K antagonists.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 12

13. Two-Level DVT Wells score
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 13

14. DVT low probability
A score of 0 or lower is associated with DVT unlikely with a
prevalence of DVT of 5%.
These patients should proceed to d-dimer testing:
A negative high or moderate sensitivity d-dimer results in a probability <1 %
and no further imaging is required.
A positive d-dimer should proceed to US testing.
A negative US is sufficient for DVT rule out.
A positive US is concerning for DVT; strongly consider treatment with
anticoagulation.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 14

15. DVT moderate probability
A score of 1-2 is considered moderate risk with a pretest probability of
17%.
These patients should proceed to high-sensitivity d-dimer testing
(moderate sensitivity d-dimer is not sufficient).
 A negative high-sensitivity d-dimer is sufficient for rule out of DVT in a moderate
risk patient with a probability of <1%.
 A positive high sensitivity d-dimer should proceed to US testing.
 A negative US is sufficient for ruling out DVT.
 A positive US is concerning for DVT, strongly consider treatment with
anticoagulation.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 15

16. DVT high probability
A score of 3 or higher suggests DVT is likely. Pretest probability 17-53%.
All DVT likely patients should receive a diagnostic US.
D-dimer testing should be utilized to help risk-stratify these DVT-likely patients.
In DVT likely patients with negative d-dimer:
 A negative US is sufficient for ruling out DVT, consider discharge.
 A positive US should be concerning for DVT, strongly consider treatment with
anticoagulation.
In DVT likely patients with a positive d-dimer:
 A positive US should be concerning for DVT, strongly consider treatment with
anticoagulation.
 A negative US is still concerning for DVT. A repeat US should be performed within 1 week for
re-evaluation.
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 16

17. Antithrombotic prophylaxis
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 17

18. Thank You
4/27/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 18