Phaware Podcast: Vic Tapson, MD, Part 2
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I’m Aware That I’m Rare: Vic Tapson, MD
The phaware™ interview (PE Part 2)
Victor F. Tapson, MD, FCCP, FRCP, from Cedars-Sinai Medical Group discusses PE treatment in Part 2 of his three-episode series on pulmonary embolism. Tapson has devoted his medical career to patient care, research, and teaching in pulmonary hypertension (PH) and pulmonary embolism.
Hi, I’m Vic Tapson. I’m in pulmonary critical care. I’m at Cedars-Sinai Medical Center in Los Angeles.
Today, I’d like to talk a little bit more about acute pulmonary embolism.
Patients that get pulmonary embolism often have certain risk factors and these risk factors tend to be based on injury to a vein, like a broken leg, broken hip, injured vein. Immobility, reduced mobility. That tends to make clots form. Finally, something called hypercoagulability. [A patient] may have a genetic problem, or certain patients have certain kinds of cancers. They may have what we might call thick blood or a hypercoagular thrombophilic state. Those patients may need more prolonged therapy. Patients with acute PE can vary in terms of the risk factors.
Sometimes we see patients that are unprovoked. They may get a clot and we can’t figure out why they got it. A long plane flight may put you at risk, but millions of people fly every day and don’t get clots. People that get clots just after plane flight, you might think, “What’s going on with this patient? There’s something unusual about them,” and consider doing some blood tests on patients like that.
Rare patients might never recover, but most patients do. Perhaps an older patient with more co-morbidities [and] more underlying, harder lung problems might take longer to recover. Someone with a big pulmonary embolism may take longer to recover. It may take days for people to start feeling better. Generally, within a period of several weeks people start to feel better, get back to normal. They often feel better in a couple of days, but before they’re really getting back to feeling comfortable getting up and around, it may be a few weeks.
There’s a syndrome people are talking about based on some research recently called post-PE syndrome. Any kind of after-PE or pulmonary embolism, they don’t feel that they recover quite as quick. Fatigue, tired, short of breath, and this may be due to persistent clot in the lung, or may be due to something else that may not be known yet. Patients may take a little longer to recover than you’d think.
We don’t necessarily need to know if a clot is gone. If somebody’s symptoms improve and they’re feeling better and getting back to normal, we don’t necessarily have to re-scan them or do other tests to see if the clot is gone. Some patients feel better kind of knowing that. We definitely re-scan people if they’re still having symptoms. If I see someone in a clinic at a month or especially three months, they’re still short of breath, we’ll do another CT scan or lung scan on them to see if that’s from residual clot in the lung, or if it’s from something else, or may be from a recurrent clot. While it’s important to know, it may seem important to know if the blood clot is gone. The most important thing is is their persistence of symptoms.
Some patients may progress and get something called chronic thromboembolic pulmonary hypertension, or CTEPH, meaning the clot doesn’t go away, a scar forms, the pressures in the lung go up because these blood vessels are narrowed and scarred. The heart can’t pump the blood through and they have CTEPH and may need surgery for this. That’s a small percentage. That’s one to three percent.
A few percentage of patients may get something called CTED (chronic thromboembolic disease), where the clot doesn’t go away. You see it on the scans and we’re still working through the definitions of CTED, but the bottom line is patients that have persistent clot on their scan without having pulmonary hypertension. Again, the bottom line is you may or may not need to really know if the clot goes away. But you really want this patient to get back to normal. You want to study their tests and look at their oxygen level, do an echocardiogram, look at their heart. If their symptoms aren’t coming back to normal, of course, consider a repeat scan.
How long to treat a PE?
Treating a pulmonary embolism is variable duration. If you have a provoked clot — let’s suppose you’ve fallen and break your hip, you got a really good reason to get a blood clot. You need to be treated at least three months with a blood thinner. We often treat people a little bit longer. If they have persisting symptoms or not going away quickly — say they have persistent leg swelling from DVT and their ultrasound shows they’ve still got some clot in their leg or still got what we call recanalization present — we may treat them longer. We may treat them for six months.
One of the key things to deciding the length of therapy is [determining if] there are persistent risk factors. If you have ongoing cancer, we generally like to continue a blood thinner as long as that active cancer is present. If you have an ongoing risk, if you’re a trauma patient and you come in the hospital and you have broken bones, you can’t get out of bed, you can’t move and you get pulmonary embolism, we’ll treat you until you’re up and walking around, whether that’s three months, six months, longer.
Then there’s a group of patients we call “unprovoked.” Unprovoked patients generally should be treated, what I would call indefinitely. Maybe forever. Or, they at least need to be watched very closely because if you get a blood clot and you can’t figure out why someone got it, that means they got it pretty easily and it means it can happen again. The duration of therapy really does depend on certain situations. If it’s a provoked clot, risk factor goes away, three months generally. If it’s unprovoked, persistent risk factors, we continue therapy.
When we see a patient back in clinic that’s had pulmonary embolism, we have to make decisions whether to do more testing. If they’ve gone back completely normal, going about their business, their work, play, everything is good, they have no shortness of breath, their oxygen is normal, we often don’t do any more testing. There’s really not a standard of care for what to do in that setting.
You always re-test someone or do some tests if they’ve not gone back to normal. We have a very low threshold. Do a V/Q Scan, which is a very sensitive test, at three months or six months, even if someone has gone back to normal. Especially if they’ve had a pretty extensive blood clot burden in their lungs. If they haven’t had any symptoms at all once they’ve recovered and everything is doing fine, we’ll examine them, talk to them, see what their symptoms are like, check their oxygen level, then decide whether we get a repeat V/Q Scan or CT Scan. The radiation from these tests, like a CT Scan, is much, much lower than it used to be. These tests are pretty safe.
We may repeat an echocardiogram to make sure it has gone back to normal. A lot of patients get an echo test of their heart. Ultrasound of the heart, that is, when they have a pulmonary embolism to see how bad, if their heart is having problems pumping against this clot burden. If that heart’s abnormal, the right ventricle or right heart’s abnormal, we like to make sure that’s gone back to normal. That’s another test we’ll often repeat when someone comes back to see us.
I’m Vic Tapson, and I’m aware that I’m rare.
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