Sun21November0420PM 6

A 26-year-old presents with a two day history of acute shortness of breath and chest pain. A CTPA is requested which reveals the presence of bilateral pulmonary emboli.

On further questioning there are no obvious precipitating factors. In particular, there is no history of recent surgery, immobility, acute illness, pregnancy or use of the oral contraceptive pill. She does however mention that her brother and mother have both suffered from pulmonary emboli.

What is the next management step?

(Please select 1 option)

Commence LMWH Incorrect answer selected

Commence LMWH and warfarin This is the correct answer

Commence warfarin

Antiphospholipid screen

Thrombophilia screen

Explanation

Testing for inherited thrombophilias is not indicated at the time of the acute event, as the utility and implications of testing need to be considered and the patient needs to be counselled before testing. There is also an acute consumption of clotting factors which can make tests difficult to interpret.

Antiphospholipid syndrome is an acquired rather than inherited disorder.

Information from thrombophilia or antiphospholipid screens should not be used to influence decisions about the initial management of VTE, but rather to help make decisions about duration of anticoagulation.

Warfarin should be started alongside a parental anticoagulant and continued for at least five days and until the INR is >2 for at least 24 hours, whichever is the longer.

Reference:

Baglin T, Gray E, Greaves M, et al. Clinical guidelines for testing for heritable thrombophilia. Br J Haematol. 2010;149:209-20.

Keeling D, Baglin T, Tait C, et al. Guidelines on oral anticoagulation with warfarin - fourth edition. Br J Haematol. 2011;154:311-24.

Keeling D, Mackie I, Moore GW, et al. Guidelines on the investigation and management of antiphospholipid syndrome. Br J Haematol. 2012;157:47-58.

Answer Statistics

1

49%

2

26%

3

1%

4

10%

5

17%

Times answered: 285