I'm Aware That I'm Rare: Vic Tapson, MD (Part 3 of 3)
Victor F. Tapson, MD, FCCP, FRCP from Cedars-Sinai Medical Group discusses PE Treatment in Part 3 of his 3 Episode Series on Pulmonary Embolism. Dr. Tapson has devoted his medical career to patient care, research, and teaching in pulmonary hypertension (PH) and pulmonary embolism.
Hi, my name is Vic Tapson. I’m in Pulmonary Critical Care at Cedars-Sinai Medical Center in Los Angeles.
Today, I’d like to talk a little bit more about acute pulmonary embolism.
There’s a lot of different symptoms that might predict pulmonary embolism and the classic one is sudden-onset shortness of breath. Someone is sitting still, doing fine, and suddenly, they’re short of breath. Not a lot of things do that. Some things do, not a lot of things. Lung collapse, pneumothorax, certain things can do that but pulmonary embolism is classic and will do that. It may be a shortness of breath, it develops over several days. Sometimes patients will have shortness of breath and it lasts for several hours and maybe goes away, and then it recurs again a week later. Now, that could be pulmonary embolism.
So chest pain, it can be pressure-like chest pain with a big pulmonary embolism that might mimic a heart attack or myocardial infarction. It could be pain in the side that we call pleuritic pain. You take a deep breath and it hurts. It can be quite painful. Some people think … they come to the Emergency Room and you got this kind of pain, well, it’s just a muscular skeletal pain, you pulled a muscle. In fact, that may be pulmonary infarction.
We always like to tell people after they’ve had a PE, if they do have a recurrence, the symptoms may be different next time. You may present with shortness of breath for your first PE and if you have a second episode, it may be chest pain, pleuritic pain, or you may have swelling and pain in the leg. You may have side pain or back pain. So we hate to make people paranoid but unfortunately, these can present in different ways. So shortness of breath is the most common symptom.
Pulmonary embolism doesn’t always go away, it usually does. There is a percentage of patients, probably somewhere between one and four percent of patients, in whom the clot doesn’t break up and go away but it stays in the lung and forms scar. These are patients who have either CTED or CTEPH. CTED is chronic thromboembolic disease. That means they’ve got some clot left in the lung, it may be causing symptoms, but they don’t have what we call pulmonary hypertension. CTEPH can occur … Now, CTEPH is what probably occurs in about one to four percent of the patients after acute PE, and that’s where the symptoms don’t go away or they may get better for a while and they get worse again. It may be six months or two years later, patient’s short of breath and we find out that … We do a scan and we find out there’s still abnormalities in the lung. We might do an Echo test, find out the pressure’s high, and eventually do a right heart catheterization and prove that there’s actually pulmonary hypertension present.
So anytime someone has pulmonary hypertension, regardless of the cause, that is high blood pressure in the lungs, we consider a V/Q scan to make sure it’s not caused by a clot. In most patients, it goes away. In some patients, it doesn’t and you may get CTED or CTEPH. Those are some of the long-term complications of pulmonary embolism that can cause shortness of breath, sometimes chest pain. These things occur in a minority of patients.
In patients that have deep vein thrombosis, some of whom get pulmonary embolism and some who don’t get pulmonary embolism, they may get something called post-thrombotic syndrome where they get pain and swelling in their legs. They’re on a blood thinner or maybe off a blood thinner. There’s no new active clot there, because you check to make sure there isn’t, and this intermittent chronic pain might occur in anywhere from 10 percent to possibly 40 percent of patients after having a clot in their leg.
There are some long-term problems from both DVT [deep vein thrombosis] and PE that can occur. So the V/Q scan, or ventilation/perfusion scan, is an important test. Now, with acute pulmonary embolism, we commonly use them if we can’t do a CT scan. Maybe you’ve got some kidney problems so we can’t give you the contrast for the CT scan, or maybe you’ve got a big pulmonary embolism, you’re in the ICU, and you can’t be moved. You’re too sick. We can do a portable V/Q scan. But one of the areas we really use V/Q scan the most effectively is if you’re a patient that comes in with pulmonary hypertension and maybe we’re working on trying to figure out why you have it and how severe it is.
Everyone with pulmonary hypertension should get a V/Q scan to make sure they don’t have pulmonary embolism causing that pulmonary hypertension because some patients with CTEPH are chronic pulmonary embolism with pulmonary hypertension … Some of these patients actually never have had a history of pulmonary embolism. They probably had a silent PE, one that was never diagnosed, and so now they’re presenting with pulmonary hypertension from that PE and the V/Q scan will pick that up.
The CT scan is a test we always follow up on but CT scans are often tricky to read in this setting. The V/Q scan, if it’s high probability, it may well be CTEPH. The CT scan is often under-read. We need some work there. The V/Q scan is a key test and one, If it’s normal, you’re off the hook and you don’t have pulmonary embolism and you don’t have CTEPH. The CT is really good for acute PE and it’s good for chronic PE or CTEPH if you got a good, experienced reader.
I’m Vic Tapson, and I’m aware that I’m rare.