What should I do for pulmonary embolism?

Question

Hi doctor,

I am a physician doing postgraduation in histopathology. I am a 29 year old female. My history is of 4 years old. I had two episodes of syncope with a period of two months followed by unilateral (right) tinnitus which disappeared on pressing the right carotid, which I totally ignored. A year later, I was diagnosed to have pulmonary embolism on the right segmental branch with the symptoms of hemoptysis, chest dyspnea, and an episode of syncope. My initial tests were performed from thrombophilia profile to every other investigation. The homocysteine level was 22 while thrombophilia profile showed protein S and factor 5 decrease. I was put on Rivaroxaban after acute treatment. I took Xeralto for a year, and then I quit. After 1.5 years from the first episode, I again developed symptoms and this time the CT angiogram showed decrease in right segmental pulmonary embolism and new left subsegmental multiple thrombi. I got my investigation repeated, and the thrombophilia profile was normal. All other examinations were normal as well. I have again put on Rivaroxaban 20 mg od after acute treatment. I had no DVT, and my echo and carotid doppler were normal. There is no past history of surgery, and I am not married neither sexually active. Last week, I again had chest pain with dyspnea. The CT angiogram showed left subsegmental thrombus with basal consolidation and pleural effusion. Now, I am switched off to Warfarin. Kindly help me regarding this to reach the diagnosis. As it is recurrent idiopathic pulmonary embolism, what should I do now?

Answer 1

Hi,

Welcome to icliniq.com.

You are getting recurrent unprovoked idiopathic pulmonary embolism (PE). The optimal duration of anticoagulation therapy after pulmonary embolism depends on the risk of recurrent venous thromboembolism after anticoagulation is discontinued. Although the best way to assess this risk is uncertain, patients with idiopathic pulmonary embolism are at higher risk for recurrence than are those with pulmonary embolism associated with transient risk factors. The incidence of recurrence is approximately 12 to 15 percent in patients with idiopathic pulmonary embolism and 7 to 8 percent in those with pulmonary embolism associated with transient risk factors. Among the patients assigned to continue therapy, the recurrence rate for venous thromboembolism is 3.1 percent per patient in a year, compared with 4.1 percent per patient in a year among the patients assigned to discontinue therapy. Some causes of recurrent PE are active cancer, antiphospholipid syndrome, inherited thrombophilic alterations, pregnancy and puerperium, hormonal therapies, obesity, polycythemia vera and essential thrombocythemia, especially in the presence of JAK2 V617F mutation. Obesity and less physical activity are the major risk factors of PE.

What should I do for pulmonary embolism?

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