How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
I would decide based on the risk of severe rebleeding and the ability of the patient to tolerate a larger PE. Recent ulcer with visible vessel and a bleed that required a few units of transfusion? Likely observe. Gastritis 3 years ago, causing UGIB, with NSAIDs since stopped? Likely anticoagulate. S...
We know that isolated subsegmental PEs have a lower risk of recurrence/progression than larger PEs, DVTs, or PEs with associated DVTs (Le Gal et al., PMID 34807722). The cumulative recurrence rate found there was 3.1%, which is lower than that for other VTE, but not low enough to feel that we can ro...
I agree with Dr. Hill's well-reasoned approach to this problem, including the part about an incidental subsegmental PE by CTA being suspect (the radiologist's opinion notwithstanding). I would also consider obtaining lower extremity venous Dopplers to evaluate for DVT. If positive, consider anticoag...
This is a challenging, but not unfamiliar question with variables that won’t be the same with every patient and will change the decision from individual to individual.
This is a risk/benefit question that does have some guidelines to help. But here we are asking does the bleed risk outweigh the clot ...
Risk of bleeding complications is too high to warrant using AC.