A 35 year-old man presents to the emergency department with left sided chest pain. The pain is pleuritic, tender, and nonpositional. It is associated with exertional dyspnea, which is new for him. He has a history of a deep vein thrombosis which had its treatment with coumadin interrupted after closure of the public-access hospital. He had no follow-up for three months.
Vital signs are 98.6 degrees Fahrenheit, heart rate 88, respirations 14 with 99% saturation on pulse oximetry on room air, blood pressure 118/56mmHg. The left sided chest pain is reproducible with palpation.
B-Natriuretic Peptide is 34.7 pg/mL, Troponin I is 0.06 ng/mL. Duplex ultrasonography of the vein revealed a deep vein thrombosis from the popliteal vein to the femoral vein. A Ventilation Perfusion scan revealed intermediate probability for pulmonary embolism. There are no resources for acquisition of outpatient enoxaparin.
The patient is admitted to telemetry. He is started on enoxaparin at 1mg/kg twice daily and Coumadin 10mg daily after his initial enoxaparin dose. The next morning he goes into respiratory distress with hypotension. The trachea is intubated, a central venous access is placed for infusion of norepinephrine, and he is transferred to the intensive care unit. An echocardiogram reveals a dilated right ventricle and an elevated pulmonary artery pressure. Tissue Plasminogen Activator is administered and the patient subsequently recovers.
The 2012 ACCP guidelines on venothromboembolism suggest that a proximal leg deep vein thrombosis (DVT) or pulmonary embolism (PE) be treated with anticoagulants1. Thrombotic therapy should be used in massive pulmonary embolism1 and can be considered in submassive pulmonary embolism2. VCF is recommended in patients who have a contraindication to anticoagulation1. The PREPIC trial revealed that in high-risk patients with proximal deep-vein thrombosis, the initial beneficial effect of VCFs for the prevention of pulmonary embolism (at day 12) was counterbalanced by an excess of recurrent deep-vein thrombosis (at year 2), without any difference in mortality2. Multiple studies have demonstrated this long-term cost cannot be offset by concurrent anticoagulation. No study has assessed whether early implantation and early removal provides benefit or not.
This patient met the criteria for outpatient DVT/PE management1. He was admitted only because of a lack of access to outpatient enoxaparin. Had this patient not been hospitalized, however, he would have died. A retrievable filter could have prevented this morbidity. Yet, should one have been placed? There is insufficient data to conclude whether a prophylactic filter should be placed in a situation like this, and the general consensus is against placement of a filter. Despite this consensus, we present a case of pulmonary embolism without heart strain or hypotension in the presence of a large, proximal deep vein thrombosis that resulted in a subsequently massive pulmonary embolism leading to significant morbidity.
Conclusions: A hospitalist is often confronted with the question in the management of venous thromboembolism, and that question remains unanswered. What is the utility of prophylactic vena cava filter (VCF) for primary or secondary prevention of massive pulmonary embolism in a patient where anticoagulation is not contraindicated?
To cite this abstract:Williams D, Witt A. Should’ve, Could’ve, Would’ve Filtered: Pe. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 501. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/shouldve-couldve-wouldve-filtered-pe/. Accessed July 17, 2019.