Latest news with #pulmonaryembolism
Medscape
7 days ago
- Health
- Medscape
You Can Manage Pulmonary Embolism in Primary Care
About 900,000 people are affected by pulmonary embolism (PE) each year in the United States, according to the American Lung Association and about 100,000 people die each year as a result of the disorder. However, some patients diagnosed with PE may be at low risk for adverse outcomes, and some experts suggest primary care physicians (PCPs) can effectively manage these low-risk patients. According to some research, it's both possible and feasible. Another potential benefit: Research also suggests that outpatient treatment for low-risk patients could reduce the burden on the healthcare system while reducing costs. Detailed Assessment to Determine 'Low Risk' The concept of treating low-risk patients with PE at home is not new. A 2022 study in the Journal of General Internal Medicine described how 652 patients diagnosed with PE in the primary care setting of a large community-based health system fared. The researchers found a very low incidence of 7-day PE related hospitalization and a low rate of 30-day serious adverse events among the adult patients who were not transferred to the emergency department or hospital. Also, in August 2022, a panel reviewed the American Society of Hematology (ASH)'s guidelines on managing deep vein thrombosis (DVT) and PE and suggested that home treatment is a possible option. The ASH Clinical Practice Guidelines on Venous Thromboembolism (VTE) stated, 'The panel also made conditional recommendations expressing a preference for home treatment over hospital-based treatment of uncomplicated cases of DVT and PE. Home treatment is suggested when there is a low risk for complications as well as a preference for direct oral anticoagulants for primary treatment of VTE.' One major component of this option, however, is making sure that a patient is actually at low risk. In fact, the authors of the Journal of General Internal Medicine study also noted that the patients diagnosed with PE in primary care tended to be at low risk, and making that determination is crucial. Typically, physicians who suspect PE begin with a physical examination of the patient. While the physician's clinical gestalt is important, many also use clinical probability scoring systems such as the Wells criteria to assess factors such as a patient's immobility, clinical symptoms of DVT, a previous DVT or PE, and hemoptysis, or the Geneva scoring system. The diagnosis of PE requires imaging studies such as computed tomographic pulmonary angiography, and lab tests, notably the D-dimer test, to confirm the likelihood of a PE. The next step is determining if the patient is at low, intermediate, or high risk. That information is crucial to making a decision about how to proceed, whether it's initiating anticoagulation treatment on an outpatient basis and sending the patient home, or it's directing the patient to go directly to the emergency department. Pulmonologist Gustavo Heresi, MD, Cleveland Clinic, Cleveland, emphasized the importance of risk stratification to determine the likely prognosis for patients once they've been diagnosed with PE. The most commonly used prognostic tool is the Pulmonary Embolism Severity Index (PESI) index, which predicts 30-day mortality in patients with PE, and its simplified version, the sPESI, which uses fewer criteria but produces comparable accuracy results. Physicians can also use the Hestia criteria, Heresi said. Gustavo Heresi, MD If a physician determines that a patient is at low risk, then it can be appropriate for a PCP to manage the patient's condition. 'The initial management can be done in the primary care setting,' said Sai Sunkara, MD, a pulmonologist with UI Health in Chicago. In fact, it's easier now than in the past, given the advances in anticoagulation therapy, such as the use of direct oral anticoagulants. 'Low-risk patients who are stable and minimally at risk, can be treated at home after getting their diagnosis and a treatment plan,' agreed Heresi. But he cautioned that he can't envision the normalization of treating intermediate- or higher-risk patients in a nonemergent setting. 'I don't think that's likely to be conducive to an outpatient treatment management plan,' he said. Even for low-risk patients, there may be some barriers to outpatient management. According to Geoff Chupp, MD, professor of medicine (pulmonary, critical care, and sleep medicine) at the Yale School of Medicine, New Haven, Connecticut, not every primary care office may have the necessary diagnostic equipment, such as CT machines. What PCPs Already Do PCPs already play a key role in caring for patients affected by PE. For example, they may educate patients at elevated risk for DVT because DVT can lead to a PE. Risk factors include cancer, a history of prior thromboembolism, pregnancy, and certain medical conditions, as well as people who have recently undergone surgery or spent time immobilized 'That's generally what we try to do is educate people,' said Lori Solomon, MD, MPH, a family physician and director of the Family Health Center at New York Medical College in Valhalla, New York. 'But sometimes you don't expect people to come in with pulmonary embolisms, so sometimes you just have to be vigilant when people come in and listen to their symptoms and take them seriously.' Lori Solomon, MD, MPH Even if the PCP does not take on the initial treatment of a PE, they still play a key role later. Around the 3-month mark, some patients become less adherent with treatment, said Branden Turner, MD, a family medicine physician with Kaiser Permanente in Los Angeles. 'It's just human nature,' he said. 'The initial fear is gone, but you still need to take your medications.' He sets up telephone appointments at regular intervals to check in with patients. However, some patients may not realize when they can discontinue their anticoagulation therapy, and PCPs can take on that role, too, said Solomon. 'It's easy to start a medication, but sometimes people forget to stop it,' she said. Prioritizing Social Determinants of Health Before a physician contemplates sending a low-risk patient home on anticoagulant therapy, they need to find out some key pieces of information. For example, Wilson Pace, MD, professor emeritus in family medicine, Anschutz Medical Campus of the University of Colorado, Aurora, Colorado, suggested determining: What is the patient's living situation? Do they have someone at home who can help them, or do they live alone? Is it possible to arrange for a home health nurse to check in on the patient at home? Does the patient have a pulse oximeter and blood pressure monitor to use at home? Branden Turner, MD PCPs are already well positioned to have or gather this type of information, said Solomon. 'That is why having a PCP is so important,' she added. 'Treatment plans and follow-up are very dependent on a patient's support system and living conditions.' Turner agreed. 'This is the crux to me of a good primary care physician: Being able to personalize the care to the patient based on the individual to get the best outcome for them,' he said. 'Health equity in practice. As long as the plan works for the patient and is safe, I'm open to navigate how to achieve the goal.'
Medscape
22-05-2025
- Health
- Medscape
Quick Turn to Mechanical Thrombectomy Improves PE Outcomes
Patients with pulmonary embolism (PE) who were treated with mechanical thrombectomy (MT) within 12 hours of hospital admission had significantly better pulmonary outcomes than patients treated with mechanical thrombectomy more than 12 hours after admission, based on new data from the FLASH registry. The benefits of prompt treatment with MT for patients with high-risk PE are evident, but data on the impact of MT timing on outcomes in patients with intermediate-risk PE are limited, wrote Krunal Patel, MD, and Parth M. Rali, MD, of the Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, in a study presented at the American Thoracic Society (ATS) 2025 International Conference in San Francisco. The FLASH registry is a prospective, multicenter registry of patients with acute intermediate-risk and high-risk PE who were followed for 6 months after treatment with a large-bore aspiration MT system, the authors wrote. 'The safety of mechanical thrombectomy has been established through the FLASH study, but as more centers adopt advanced interventions such as MT and catheter-directed thrombectomy, it is critical to determine the optimal timing for these procedures,' Patel said in an interview. 'Understanding when to intervene could significantly impact outcomes for patients with pulmonary embolism,' he said. The researchers classified 726 patients with intermediate-risk PE into two groups: Short time to MT (short TtMT, defined as 12 hours or less) and long time to MT (long TtMT, defined as more than 12 hours). The short TtMT group included 215 patients with a median time of 6.12 hours to treatment, and the long TtMT group included 511 patients with a median of 24.78 hours to treatment. Patients were assessed for outcomes including mean pulmonary artery pressure (mPAP) and systolic pulmonary artery pressure (sPAP), as well as right ventricle to left ventricle (RV/LV) ratio, distance on the 6-minute walk test, and Pulmonary Embolism Quality of Life score. At baseline, patients in the short TtMT group had a higher lactate and higher RV/LV ratio than those in the long TtMT group. Both mPAP and sPAP reductions were significantly greater in the short TtMT group vs the long TtMT group (9.0 mm Hg vs 7.0 mm Hg and 14.0 mm Hg vs 12.0 mm Hg, respectively; P < .0001 for both). Patients in the short TtMT group also had greater reductions in RV/LV ratios from baseline to follow-ups of 48 hours, 30 days, and 6 months than those in the long TtMT group. The short TtMT group also had a significantly longer median distance on the 6-minute walk test at the 6-month follow-up visit than the long TtMT group (450.5 m vs 390.0 m; P = .0260). No differences in safety events including major bleeding through 48 hours and mortality at 30 days were observed between the groups. Revised Guidance Needed 'We suspected, much like with [ST-elevation myocardial infarction] STEMI and stroke, that the principle of 'time is tissue' would apply, meaning that earlier intervention would lead to better outcomes,' Patel told Medscape Medical News . 'We focused solely on intermediate-risk PE patients to limit confounding from illness severity, and we observed meaningful clinical improvements in the early group,' he said. One major barrier to the rapid initiation of MT following hospital admission is that current guidelines haven't kept pace with emerging interventional strategies, Patel told Medscape Medical News . 'Broad adoption requires consensus and updated protocols,' he said. 'Implementing a Pulmonary Embolism Response Team (PERT) can also be pivotal in streamlining patient evaluation and ensuring timely access to advanced therapies,' he noted. 'A prospective trial would provide the strongest evidence but may be challenging in high-risk patients, where most clinicians already agree on the need for rapid intervention, and in the meantime, we rely on retrospective data,' said Patel. 'More importantly, we need to revise how we classify PE patients,' he said. A modern classification system should integrate multiple therapies including MT into the risk stratification framework, Patel said. 'Globally, a patient dies of a PE every minute, and with advanced interventions this will hopefully become a thing of the past, but more focus needs to be taken on timing and developing a new way of classifying patients so interventions can take an algorithmic approach incorporating these new treatment modalities,' he said. Data May Drive Increased Use of Technology 'The treatment of intermediate-risk pulmonary embolism is one of the clinical areas where there is wide variability because the data we have leaves room for interpretation,' said Anthony Faugno, MD, a pulmonologist at Tufts Medicine, Boston, in an interview. Not every center has advanced invasive capabilities for MT, he noted. 'More clarity on the benefits of these invasive therapies will help individual centers identify the need to adopt these technologies and build systems for their best use,' Faugno said. Regarding the current study, 'Being that this was a registry and not a randomized controlled trial, it is likely that the patients in the early intervention group were recognized as being clinically sicker, resulting in faster treatment,' Faugno told Medscape Medical News . The baseline differences in RV/LV ratio and lactate support that a sicker group received earlier intervention, and one would expect their hemodynamics to benefit more, he said. 'It is surprising that the sicker initial group had enhanced quality of life at follow-up, but it is hard to draw conclusions about this without an understanding of the different comorbidities in each group,' he noted. Because the current study did not adjust for factors such as chronic medical illness that might affect patient function at 6 months, the results should be interpreted with some caution, Faugno noted. However, more data such as these may prompt more centers to rapidly mobilize the resources needed for invasive procedures in cases of intermediate-risk PE, he said. As for additional research, 'I think the most important clinical question in the intermediate-risk pulmonary embolism group is deciding who can be treated with systemic anticoagulation alone and who benefits from the invasive, and sometimes costly, procedures,' Faugno told Medscape Medical News . 'There are some centers, specifically small and rural hospitals, that will be unable to provide advanced invasive treatments at all hours,' he noted. 'I think there is still a benefit to noninvasive treatment of intermediate-risk pulmonary embolism in the properly selected patient; research to understand who these patients are will help us develop future clinical trials on treatments,' he said. The study received no outside funding.
Daily Mail
14-05-2025
- Health
- Daily Mail
Actress's parents take fight to the courts after daughter, 30, died when 'physician associate' she wrongly believed was a doctor misdiagnosed her
The parents of a 30-year-old actress who died after a 'physician associate' she wrongly believed was a doctor misdiagnosed her twice are taking their case to court. Emily Chesterton died only three weeks after her 30th birthday in 2022 when a clot in her lungs was mistaken for anxiety and a strain. She believed she had been seen by her GP at her surgery in London but it was a physician associate who prescribed her propranolol, medication for anxiety. Emily, from Greater Manchester, but who had moved to London to pursue a career in acting, collapsed later that evening. Although she was rushed to hospital, her heart had stopped beating, and doctors could not save her life. A coroner concluded Emily could have been saved if she had been to A&E and given treatment for a pulmonary embolism. Her parents, Marion and Brendon Chesterton, are now launching a legal fight against the General Medical Council (GMC) demanding more regulation. Doctors are fully licensed medical professionals who diagnose, prescribe, and perform surgeries independently after years of training. Her parents, Marion and Brendon Chesterton, are now launching a legal fight against the General Medical Council (GMC), with Anaesthetists United, saying that PAs, and anaesthesia associates (AA) should be properly regulated Physician associates support doctors by carrying out many clinical tasks but must work under a doctor's supervision and typically cannot prescribe or operate. Their role helps ease pressure on healthcare systems, though it remains a topic of debate. Ms Chesterton's symptoms included calf pain, a swollen and hot leg, shortness of breath and she was finding it increasingly difficult to walk. After reaching out to the practice the first time, the PA recommended she take paracetamol, but her condition became worse and at one point was having difficulty walking and was breathless and lightheaded, her mother told the BBC. She claims the second appointment her daughter was diagnosed with calf sprain, long Covid and anxiety but her calves were not examined and never made clear she was not a doctor. Ms Chesterton actually had a blood clot in her left leg, which led to her dying of a pulmonary embolism. Her father, Brendon, said everyone he had spoken to had told him that a pain in the calf was 'medical 101' that it was a clot. 'We've said the name (physician associate) is rather grand,' he said. 'A physician associate sounds even better than junior doctor. The name itself we objected to. We were told nothing could be done about the naming of them. But it suggests someone who is highly trained and highly competent. Marion and Brendan Chesterton say their daughter, Emily, would still be alive if a physician associate had sent her to A&E rather than misdiagnose her blood clot symptoms as 'anxiety' 'But people I've talked to, they say a pain in the calf is like medical 101. Everyone should realise that that is indicative of some kind of clot. She didn't notify that.' The GP practice where Emily was seen, the Vale Practice in Crouch End, has since stopped employing PAs. Backed by the British Medical Association, the Chesterton family is launching a legal battle with the General Medical Council, accusing it of a failure to uphold its legal duties. They claim the lines between doctors and non-doctors have become blurred, putting patients at risk. They're asking the GMC to issue a scope of practice document laying out exactly what each role can do to ensure patient safety and clarify expectations. Speaking outside the Royal Courts of Justice, Marion Chesterton said: 'To lose a child is so painful, it is not the right order of this world. 'However, to lose a child and then discover it was avoidable is the worst pain ever. 'We do not want anyone else going through the torture we have endured. Physician associates and anaesthesia associates must be regulated thoroughly, they must be properly supervised.' Mrs Chesterton said: 'We're here to honour our daughter, to make sure that this doesn't happen to any other family. No more Emilys. 'We're here to ask the GMC to do their job and regulate, it's been assigned to them by Parliament, so they've got to do the job. 'If I didn't do this. I'd just lie down in a ditch somewhere and let the world pass me by. I've had to do it because I was so angry. 'When I found out that PAs weren't regulated I was absolutely devastated, I thought "this, this is wrong".' At the start of the hearing on Wednesday, Mrs Justice Lambert said: 'This case is not just about regulation of assistants, it is about regulation of the medical profession, and that is how I see it.' Thomas De La Mare KC, representing the Chestertons and Anaesthetists United, told the court: 'At its heart, this case is critically about risk and about the regulation response to risk.' In written submissions, he said the GMC is 'failing to fulfil its regulatory role on an ongoing basis and this court should find that that is unlawful'. Mr De La Mare also said the GMC had failed to produce guidance or set standards either for the doctors supervising associates, or for the associates themselves. It has further failed to 'gather sufficient information to address the question of how it should regulate associates, then lawfully address and answer that question', the court was told. Mr De La Mare continued: 'The GMC's foundational premise, never consulted upon, that the system for regulating doctors would be appropriate for regulating associates, was and is fundamentally flawed.' In written submissions, Rory Dunlop KC, for the GMC, said the argument for a defined scope of practice raises the question of whether it would be in the public interest to impose such 'rigid' limits on PAs and AAs. Saying the court has no 'expertise or experience' in this field, he continued: 'There might be benefits to public safety of imposing limits of the kind that claimants suggest. 'However, there might also be harm to public safety in imposing such limits, e.g. such limits would prevent PAs and AAs from developing their skills, in a suitable supervised setting, and might inhibit some PAs and AAs from doing work they could be competent to do. 'If so, that would have a negative impact on the stretched resources of the NHS and the capacity of doctors to deal with more complex patient issues. 'That, in turn, would have a negative impact on patient safety by making it less likely that patients can get the timely treatment they need.' He added that no party in the proceedings considers that the GMC is the body best placed to define the scope for PAs or AAs. The hearing before Mrs Justice Lambert is due to conclude on Thursday with a decision expected in writing at a later date.
