time keeps on tickin’…


How long should we treat this patient with a PE?
We all get good at diagnosing and acutely treating PE in the acute care setting.  Often, we turf the decision of how to manage them to the clinic.  But today you are in the clinic and it’s in your lap.  So, what to do?
Our patient is 52 with well controlled hypertension on one medicine. He presented to the ED with chest pain and was found to have a PE.  He was admitted and treated appropriately with Lovenox and Coumadin. He has been following up in Coumadin clinic and is appropriately anticoagulated now.  He wants to know how long he needs this Coumadin.
Well, that depends….
Here’s an article that goes through a lot of these issues, and it is worth a read if you are interested.
But the things to balance are the risk of repeat clot and the risk of bleeding.
Risk of clot 
This has to do with reasons for clot and underlying patient factors.
  • Low risk (3% year): major reversible risk- surgery
  • Intermediate risk (5% year): minor reversible risk- travel, estrogen (Rx or pregnancy), trauma
  • High risk (10%): irreversible risks-  unprovoked clot, untreated malignancy
The various hypercoagulable states all have their own risk levels for repeat clot.
  • Antiphospholipid antibodies and homogyzotes for Factor V Leiden are on the high end of the risk spectrum.  
  • Heterozygotes for Factor V Leiden may have no increased risk of clot, unless they also carry a copy of the prothrombin gene mutation.
Risk of bleeding
There are clinical prediction tools for this.  Here’s one: (RIETE registry: Thromb Haemost 2008; 100:26-31)
Recent major bleed: 2 points
Elevated Creatinine >1.2: 1.5 point
Hemoglobin <13: 1.5 points
Malignancy: 1 point
Overt PE: 1 point
Age >75: 1 point
Add up the points
0=low risk (0.3 per 100 patient trimesters- I admit to not knowing what this means in real life)
1-4= moderate risk (2.6)
>4=high risk (7.3)


Expert guidelines
ACCP recommends:
  • First provoked DVT or PE: 3 months
  • First unprovoked DVT or PE: 3-6 months
    • DVT/PE with malignancy: until malignancy is “controlled”
  • Recurrent DVT/PE or thrombophilia: indefinite


A pain in the head

Not sure why I always post about pain on Fridays, but here I go again. We’ve had some discussions about headaches in Red Clinic lately (and I don’t mean the VA formulary), and I thought it would be useful to review some diagnostic strategies.


Remember the mnemonic:  POUND Pulsatile One day Unilateral Nausea Daily activity (Interferes with daily activity) These are intense, debilitating headaches, often with  nausea and photo/phonophobia. Patients will “take to the bed” to get over them. May have an aura: visual or sensory disturbances that are fully reversible.

Tension Headache

Milder in intensity, bilateral, throbbing in quality. May have muscle tenderness over the scalp or neck. Patients usually can stay at work, continue activities with these headaches.

Cluster Headaches

Rare Patients  have episodes of daily headache, intense, usually unilateral and associated with autonomic symptoms.  They will have symptom free periods between “clusters” for months or even years.

Medication Rebound Headache

Common Daily headache associated with regular use of almost any medicine for headache treatment.  Most common with opiates, butabital containing meds (Midrin), or caffeine containing meds (fioricet or excedrin). Intermediate risk of triptans. Lowest risk with NSAIDs.

More is Less

Just a quick post today- sort of a philosophical discussion about ordering tests, medicines, and just providing too much medical care.  I tend to espouse the idea that I should mostly educate and get out of the way.  I spend a lot of time talking people out of tests and medicines, and pointing out that more medical care leads to more problems.

A blog post from one of my favorite primary care docs points this out, in his typical entertaining fashion.  Take a look and see what you think:

Musings of a Distractible Mind- More Trouble

I’ve got  a link to his blog in the blog roll to the right-  you might think about following him if you are into reading blogs.  He’s just started a new practice, more of a concierge/direct pay model, which is really interesting to think about and watch him work through the kinks. Enjoy!