Would you order another Computed Tomography Angiography (CTA) for a patient with a recently diagnosed Pulmonary Embolism (PE) presenting with continued shortness of breath?

From the Guidelines

I would not routinely perform another CTA for a patient with recently diagnosed pulmonary embolism (PE) who presents with continued shortness of breath. Instead, I would focus on evaluating the adequacy of the current anticoagulation therapy and ruling out other causes of persistent symptoms. The patient should be assessed for proper dosing of anticoagulants such as enoxaparin (1 mg/kg twice daily), rivaroxaban (15 mg twice daily for 21 days, then 20 mg daily), or apixaban (10 mg twice daily for 7 days, then 5 mg twice daily) as recommended by the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism 1.

Some key points to consider in the management of this patient include:

• Evaluating the patient's clinical probability of PE using validated criteria, such as the Wells score or the Geneva score, as recommended by the 2019 ESC guidelines 1
• Assessing the patient's symptoms and signs, such as shortness of breath, chest pain, and oxygen saturation, to determine the severity of the condition
• Considering alternative diagnoses, such as pneumonia, chronic obstructive pulmonary disease (COPD), or heart failure, that may be contributing to the patient's symptoms
• Monitoring the patient's response to anticoagulation therapy and adjusting the dose as needed to prevent complications, such as bleeding or recurrent PE

A repeat CTA would be warranted only if there is clinical suspicion of PE extension despite adequate anticoagulation, development of new symptoms suggesting a complication like pulmonary infarction, or if the patient shows signs of hemodynamic instability, as suggested by the 2019 ESC guidelines 1. Other diagnostic tests like echocardiography to assess right ventricular function or oxygen saturation monitoring would be more appropriate for evaluating the patient's current condition and response to treatment. The 2019 ESC guidelines also recommend follow-up imaging only in patients with risk factors for development of chronic thromboembolic pulmonary hypertension (CTEPH) or in patients with persistent or recurrent symptoms 1.

In terms of specific management, the patient should be assessed for proper dosing of anticoagulants, and the dose should be adjusted as needed to prevent complications. The patient should also be monitored for signs of bleeding or recurrent PE, and alternative diagnoses should be considered and ruled out. Overall, the goal of management is to prevent complications, improve symptoms, and reduce the risk of recurrent PE, while also minimizing the risk of bleeding and other adverse effects of anticoagulation therapy.

From the Research

Patient Presentation and History

• The patient has been recently diagnosed with pulmonary embolism (PE) at another emergency room and presents to this ER with continued shortness of breath.
• The patient's history of PE is relevant in determining the best course of action for their current symptoms.

Diagnostic Considerations

• A computed tomography angiogram (CTA) is typically used to diagnose PE, but the question is whether to perform another CTA given the patient's recent diagnosis and ongoing symptoms.
• There is no direct evidence in the provided studies to suggest that repeating a CTA is necessary or beneficial in this scenario.

Treatment Options for PE

• The provided studies discuss various treatment options for PE, including oral anticoagulation 2, mechanical thrombectomy 3, 4, and systemic thrombolysis 3.
• Mechanical thrombectomy has been shown to be a promising alternative to systemic thrombolysis in patients with high-risk PE and contraindications to thrombolytic therapy 4.
• However, the decision to perform another CTA or proceed with treatment is not directly addressed in the provided studies.

Clinical Decision Making

• The clinical decision to perform another CTA or proceed with treatment should be based on the patient's individual presentation, medical history, and risk profile.
• The studies provided do not offer direct guidance on this specific scenario, and the decision should be made on a case-by-case basis, considering the patient's overall clinical picture 2, 3, 4.