Pulmonary embolism in older adults: symptoms, diagnosis and anticoagulant treatment

The NHS describes a PE as a blood clot blocking a blood vessel in the lungs, which can be life-threatening if not treated quickly. It often happens when part of a clot dislodges from the leg and travels up to the lungs. A hospital leaflet from Cambridge University Hospitals explains that deep vein thrombosis (DVT) and PE together are known as venous thromboembolism, and that a PE scan often shows "multiple PEs" because the clot breaks into pieces; the number does not usually change treatment.

In about half of people with a DVT or PE the clotting balance has been shifted by a recognised provoking factor, the leaflet says, such as hospitalisation in the previous three months including operations, major trauma or fractures, pregnancy, oestrogen-containing medicines, several days of immobility, or cancer. Recent hospital stays, operations, fractures and spells of immobility, which are more frequent in later life, are among the recognised provoking factors.

The NHS lists sudden difficulty breathing, chest pain that is worse when you breathe in, and coughing up blood, with possible pain, redness and swelling in one leg, usually the calf. Kingston and Richmond NHS Foundation Trust adds a fast heart rate and feeling faint or passing out. NICE CKS lists dyspnoea, haemoptysis, chest pain, syncope or pre-syncope, rapid breathing and features of DVT, and says that when PE is suspected other causes of symptoms such as acute coronary syndrome and pneumonia should be excluded.

In an older person, a clot may show up mainly as unexplained breathlessness or a faint rather than the classic chest pain. Because breathlessness is also common with heart failure, COPD and chest infection, anyone with new or sudden worsening breathlessness, particularly after surgery, a fracture or a hospital stay, should be assessed urgently.

The NHS says to ask for an urgent GP appointment or contact NHS 111 if you have sudden difficulty breathing or are coughing up blood. It says to call 999 or go to A&E for severe difficulty breathing, pain in the chest or upper back, a very fast heartbeat, or if someone has passed out. It says not to drive to A&E, and to bring any medicines. If a GP suspects PE, you are sent to hospital for tests and treatment. NICE CKS adds that immediate hospital admission is advised for anyone with signs of instability, who is pregnant or has recently given birth.

NICE CKS describes using the two-level PE Wells score to estimate probability. If PE is likely, hospital admission for an immediate computed tomography pulmonary angiogram (CTPA) is arranged, with interim anticoagulation if the scan cannot be done at once. If PE is unlikely, a D-dimer blood test is arranged, with results available within 4 hours; if positive, the person goes for CTPA; if negative, interim anticoagulation is stopped and another diagnosis considered. The Cambridge leaflet says the diagnostic scan is usually a CT or VQ scan.

The NHS says that at hospital you will probably be given an injection of anticoagulant before you get any test results.

The NHS says anticoagulants stop clots getting bigger and prevent new ones forming. If tests confirm PE, injections continue for at least 5 days and anticoagulant tablets for at least 3 months. The Cambridge leaflet explains that oral anticoagulants such as rivaroxaban, edoxaban or apixaban act immediately and do not need level monitoring, whereas warfarin takes up to five days to work, is covered by heparin at first, and needs regular INR blood tests. Kingston and Richmond adds low molecular weight heparin injections and dabigatran as options, and says the choice takes account of other health conditions. People at lower risk may be treated as outpatients; those at medium or high risk are admitted.

Duration depends on the cause. The Cambridge leaflet describes about 12 weeks for a clearly provoked PE, and consideration of long-term anticoagulation for unprovoked PE with a clinic review. NICE CKS says people with unprovoked PE should be offered investigations to assess the possibility of undiagnosed cancer. Follow-up in primary care includes monitoring treatment and ensuring the person has an anticoagulant information booklet and alert card. Do not stop the tablets before the stop date given, and do not stop early without the team's advice.

Kingston and Richmond explains that blood thinners increase the risk of bleeding, so you are given an anticoagulation alert card to carry. It says to get medical attention for unexpected or uncontrollable bleeding, a fall or injury to the head, coughing or vomiting blood, blood in urine, black or bloody stools, severe unexplained bruising, or a severe headache that will not go away with dizziness or weakness. It advises avoiding over-the-counter non-steroidal anti-inflammatories such as ibuprofen, naproxen and diclofenac, and asking about aspirin; paracetamol, codeine, co-dydramol or co-codamol are painkillers it lists as acceptable. For older adults prone to falls, a head injury while on anticoagulants always needs prompt medical assessment.

It also says you may return to work within a few weeks depending on symptoms, and should not fly for at least 2 weeks or longer if unwell, speaking to the GP first.

The Cambridge leaflet suggests improving fitness and mobility, reducing weight if the body mass index is above 30, stopping smoking, avoiding oestrogen-containing hormones, and telling doctors and nurses about a previous DVT or PE if admitted to hospital or after an operation or leg immobilisation, so preventive treatment can be arranged. The NHS says hospital teams should take steps to prevent DVT in people being treated for other conditions, and lists travel advice: move often, drink water, bend and straighten the legs and feet every 30 minutes, avoid long periods without moving, and wear flight socks; the risk is increased for flights over 4 hours. Kingston and Richmond suggests moving your legs at least every 4 hours if not mobile, though this varies with individual risk.