Pulmonary embolism – what patients experience

The two most common forms of venous thromboembolism (VTE) are deep vein thrombosis (DVT) and pulmonary embolism (PE). In the UK, about 39 to 115 per 100,000 of the population each year will develop a PE and the mortality rate can be up to 30%. However, “what we’ve started to realise in recent times is that not all PEs are the same and actually there’s distinct groups within that bracket”, says Mr Power. Patients with high-risk (usually large) PEs are critically unwell and require hospital admission.  Patients with low-risk (usually small) PEs can often be managed as outpatients.

How are high and low-risk pulmonary embolisms diagnosed and managed?

A computed tomography pulmonary angiogram (CTPA) is now the first line diagnostic modality for suspected pulmonary embolism, explains Mr Power.  It allows clinicians to identify large and small pulmonary emboli.

In the past there were significant inconsistencies in the management of PE. For example, 50% of DVT patients in Swansea did not receive any follow-up.  The 2019 NCEPOD report of PE management identified similar inconsistencies nationwide. In 2020 the British Thoracic Society (BTS) published quality standards for outpatient PE management and the team in Swansea used this a prompt to review its own services and a catalyst to develop the new service.

How the pulmonary embolism pathway ensures consistent decision-making

The pulmonary embolism pathway has been designed to ensure acute risk assessment and appropriate follow up for all pulmonary embolism patients whether treated as inpatients or outpatients.

Routine risk assessment using the PE severity index (PESI) was introduced for all PE patients. In addition, seven-day and long-term follow-up was put in place. Steps were also taken to ensure that that those patients who initially required hospital admission later entered the same standardised follow-up pathway.

The Swansea model differs from others in that it covers the whole pathway in an integrated way rather than separating the acute phase and the follow-up phase. “So, we have this ideal pathway from day one to month three.  Patients will come into that pathway at different points but the idea is that eventually we reach the same point and because it’s the same group of clinicians doing it, we get the consistency. …. Every patient referred into the service – it doesn’t matter from which point – they will have that input and they’ll have that consistency of decision making”, says Mr Power.

What impact has the pulmonary embolism pathway had?

During the 12-month period September 2022 to the end of August of 2023 some 300 pulmonary embolism (PE) referrals were received. Of these, 89 were managed as ambulatory patients; the 30-day readmission rate was 4% and only 3% required referral to the respiratory team.

At the critical seven-day review, patients undergo a full clinical assessment. As this is done in the Same-Day Emergency Care (SDEC) unit there is immediate access to other specialists if the patient’s clinical status is declining.

One of the biggest challenges was tackling his own strongly-held view that further development of pharmacists’ advanced practice skills was required. A framework for practice has now been developed together with an extensive training programme. The advanced practice training ensures that “we actually add things on to our skills to make us better as prescribing clinicians within that area”, says Mr Power.

How to establish a sustainable pulmonary embolism service

A number of features have contributed to the success of the pharmacy-led outpatient PE pathway including a close working relationship with the doctors, the systematic delivery of seven-day follow-up and pharmacists’ acquisition of advanced practice skills.

Pharmacists now make all the decisions about duration of anticoagulation.  As a result, some registrars and other junior doctors have sat in on pharmacists’ clinics – an experience that Mr Power says has been mutually beneficial.

Anecdotal feedback from patients suggests that those who have gone through the ambulatory pathway tend to be less anxious. “Patients really do seem to respond really well to the service and are very appreciative of having that prompt follow-up”, says Mr Power.

The PE pathway “was the natural next step to ensure that we have a fully comprehensive VTE service which is addressing all of the most common presentations of VTE and offering a high-quality service …. that’s delivering good patient outcomes and is sustainable”, he says. The current arrangement is funded to provide 37.5 hours per week of VTE service, he adds.

The main priority for the immediate future is to develop further the working framework and training process.  Mr Power hopes that in future this might form the basis of a national training framework for pharmacists and other health care professionals who wish to work in this area.

About Kieron Power

Kieron Power is Principal Pharmacist for Thrombosis and Anticoagulation in Swansea Bay University Health Board in South Wales.  His role comprises three elements:

• Thrombosis and Anticoagulation Lead for the health board – a governance role that involves leading on policy and guidance within the Health Board and performance monitoring for hospital-acquired thrombosis rates, venous thromboembolism risk assessments and general anticoagulation prescribing factors.
• Running a weekly thrombosis and anticoagulation specialist clinic on behalf of the consultant haematologists.
• Leading and running the pharmacist-led acute VTE service and follow-up service that operate within the health board

Read and watch the full series on our website or on YouTube.

One concern that is often voiced is the issue of whether junior doctors become de-skilled at some aspects of patient care because clinical pharmacists have taken them over. Mr Power acknowledges that junior doctors now make decisions about duration of anticoagulation less frequently than in the past, “because when we see patients to that three-month point, one of the key things that we do is decide, ‘how long are we going to anticoagulate this patient for?’ – and actually we are doing that almost exclusively within the Health Board”.  As a result, some registrars and other junior doctors have sat in on pharmacists’ clinics – an experience that Mr Power says has been mutually beneficial. “I’ve been very keen to learn from them in terms of their skill set, in terms of how they would approach certain aspects and they’ve been very keen to learn from me.  Again, I think that’s been a really positive experience, especially because we’re working at this advanced practice level, that we’re able to have a little bit of an idea sharing as well so that we’re continuously improving what we’re delivering to our patients”, he says.

Patients who have experienced a pulmonary embolism (PE) are very anxious. Anecdotal feedback from patients suggests that those who have gone through the ambulatory pathway tend to be less anxious. This may be because “they don’t really associate themselves as having an acute serious condition until they’re told following the CTPA (computed tomography pulmonary angiogram).  The patients who have far more traumatic events and are hospitalised have far greater levels of anxiety”, explains Mr Power. Prompt follow-up appears to a major factor contributing to  patient satisfaction. “We offer a dedicated clinic for VTE (venous thromboembolism), we have the knowledge of the condition, we’re able to sit down with the patient and have a discussion around the diagnosis to help them to understand how the recovery process works”, he says. “Patients really do seem to respond really well to the service and are very appreciative of having that prompt follow-up”, he adds.

Comprehensive VTE management

The outpatient PE pathway adds an extra dimension to the existing VTE service. Initially the service was primarily focused on the management of deep vein thromboses (DVTs) and cancer-associated thromboses.  The PE pathway “was the natural next step to ensure that we have a fully comprehensive VTE service which is addressing all of the most common presentations of VTE and offering a high-quality service …. that’s delivering good patient outcomes and is sustainable”, he says.

The current arrangement is funded to provide 37.5 hours per week of VTE service. The team is able to handle both new and follow-up patients and it receives referrals from the SDEC (Same-Day Emergency Care) unit where it is based and other Health Boards.

The main priority for the immediate future is the working framework and training process.  An 18-month competency-based training programme that includes much supervised and  semi-supervised practice has been developed. Mr Power hopes that in future this might form the basis of a national training framework for pharmacists and other health care professionals who wish to work in this area.

About Kieron Power

Kieron Power is Principal Pharmacist for Thrombosis and Anticoagulation in Swansea Bay University Health Board in South Wales.  His role comprises three elements:

• Thrombosis and Anticoagulation Lead for the health board – a governance role that involves leading on policy and guidance within the Health Board and performance monitoring for hospital-acquired thrombosis rates, venous thromboembolism risk assessments and general anticoagulation prescribing factors.
• Running a weekly thrombosis and anticoagulation specialist clinic on behalf of the consultant haematologists.
• Leading and running the pharmacist-led acute VTE service and follow-up service that operate within the health board

Read and watch the full series on our website or on YouTube.

During the 12-month period September 2022 to the end of August of 2023 some 300 pulmonary embolism (PE) referrals were received. Of these, 89 were managed as ambulatory patients and the 30-day readmission rate was 4%. Furthermore, only 3% required referral to the respiratory team.  These results showed that patients with low-risk PE could be safely managed as outpatients.  “The idea is that these patients who are managed and recover well and don’t seem to have any complication – they were being kept out of those highly specialist services so that they could focus on the groups of patients who do need that specialist input”, said Mr Power. The numbers show that about 30% of patients were removed from the general PE pathway and managed safely and efficiently via the outpatient pathway.

The seven-day review is a critical aspect of the service. “These patients with the lower risk PEs – it’s still a very, very concerning event for them. …. There is quite a lot of anxiety for a patient with a PE so having that seven-day review is really useful from that perspective”, he emphasises. At the seven-day review patients undergo a full clinical assessment. As this is done in the Same-Day Emergency Care (SDEC) unit there is immediate access to other specialists if the patient’s clinical status is declining.

The pharmacists work as part of a multidisciplinary team (MDT) alongside senior GPs and consultant physicians. The out-patient PE pathway was developed in discussion with the other members of the MDT. “We had very productive discussions around pathways and such and it was for the better that we had those discussions because we were able to iron out some of the finer details”, recalls Mr Power.

One of the biggest challenges was tackling his own strongly-held view that further development of pharmacists’ advanced practice skills was required. Mr Power explains:  “I was very keen for us as pharmacists to focus on what I feel our skills are – which is fundamentally in therapeutics. VTE, in general, is primarily a drug-managed condition – and especially in the groups of patients which we’re talking about – these lower-risk outpatients. But I feel that it’s a slightly more complex condition to understand [in terms of] what a good outcome looks like”.

A framework for practice has now been developed together with an extensive training programme. The advanced practice training ensured that “we actually add things on to our skills to make us better as prescribing clinicians within that area”, he says.

About Kieron Power

Kieron Power is Principal Pharmacist for Thrombosis and Anticoagulation in Swansea Bay University Health Board in South Wales.  His role comprises three elements:

• Thrombosis and Anticoagulation Lead for the health board – a governance role that involves leading on policy and guidance within the Health Board and performance monitoring for hospital-acquired thrombosis rates, venous thromboembolism risk assessments and general anticoagulation prescribing factors.
• Running a weekly thrombosis and anticoagulation specialist clinic on behalf of the consultant haematologists.
• Leading and running the pharmacist-led acute VTE service and follow-up service that operate within the health board

Read and watch the full series on our website or on YouTube.

The new pulmonary embolism (PE) pathway built on the existing pharmacy-led venous thromboembolism (VTE) service. The first step was a department-wide review of the way in which outpatient PE care was managed. Routine risk assessment using the PE severity index (PESI) was introduced for all PE patients. “What the BTS (British Thoracic Society) recommends is that patients who are class one or class two on the PESI score can usually be considered for ambulatory care”, notes Mr Power. The presence of right ventricular strain, troponins and BNP (B-type natriuretic peptide) are also taken into account, he adds. Importantly, the initial assessment also considers social factors that could affect a patient’s ability to handle ambulatory care. “So, we developed our criteria for patients …. who presented to the SDEC (same-day emergency care unit) [to determine] who could be managed as ambulatory patients and which patients would need to be admitted into hospital”, he says.

The second step was to put in place mechanisms to ensure both short- and long-term follow up.  The BTS quality standards stipulate follow up within seven days of discharge.

“We utilised our pharmacist-led VTE service to undertake those seven-day reviews and what that fundamentally means is bringing the patient back, clinically reviewing them, reviewing their symptoms, reviewing them from the perspective of their observations listening to their chest …. and just making sure that nothing has changed in their clinical status and they remain suitable for ambulatory care. And that’s proved extremely useful”, Mr Power explains.

Steps were also taken to ensure that that those patients who initially required hospital admission later entered the same standardised follow-up pathway. This was achieved by referral to the VTE service so that the discharge from hospital was managed by the VTE team and the patients were started on the follow-up pathway.  Part of the follow-up process involves checking for a cause of the initial VTE and screening for long-term complications.  “Some patients, unfortunately, are prone to long-term complications after having a PE. One of them is a condition called CTEPH or chronic thromboembolic pulmonary hypertension, which is where patients fail to clear the thrombi from their lungs and they develop a pulmonary hypertension. It is an extremely disabling condition”, he explains.  Patients who are felt to be at risk of respiratory complications can be referred to respiratory teams.

The Swansea model differs from others in that it covers the whole pathway in an integrated way rather than separating the acute phase and the follow-up phase. “So, we have this ideal pathway from day one to month three.  Patients will come into that pathway at different points but the idea is that eventually we reach the same point and because it’s the same group of clinicians doing it, we get the consistency. …. Every patient referred into the service – it doesn’t matter from which point – they will have that input and they’ll have that consistency of decision making”, says Mr Power.

About Kieron Power

Kieron Power is Principal Pharmacist for Thrombosis and Anticoagulation in Swansea Bay University Health Board in South Wales.  His role comprises three elements:

• Thrombosis and Anticoagulation Lead for the health board – a governance role that involves leading on policy and guidance within the Health Board and performance monitoring for hospital-acquired thrombosis rates, venous thromboembolism risk assessments and general anticoagulation prescribing factors.
• Running a weekly thrombosis and anticoagulation specialist clinic on behalf of the consultant haematologists.
• Leading and running the pharmacist-led acute VTE service and follow-up service that operate within the health board

Read and watch the full series on our website or on YouTube.

A CTPA (computed tomography pulmonary angiogram) is a scan that enables visualisation of the vasculature of the lungs allowing clinicians to identify defects in perfusion that would indicate the presence of a pulmonary embolism (PE). CTPA is now the first line diagnostic modality for suspected pulmonary embolism, explains Mr Power.

In the past, smaller, low-risk pulmonary emboli could present with non-specific symptoms and initially be diagnosed as respiratory tract infections or pneumonia. When such patients failed to respond to antibiotic treatment a pulmonary embolism might be suspected. Alternatively, if a patient has risk factors for a PE and the managing clinician feels that they can’t rule out a PE, then they may be sent for a CTPA. “Interestingly,  … what we’ve seen over recent years is – because of advances in diagnostic tools like CTPA – what we’ve seen is that actually the number of PE diagnoses have gone up but … mortality is actually decreased over time”, says Mr Power. This is thought to be due to the increased sensitivity of CTPA (compared to ventilation-perfusion (VQ) scans). “What we’re actually seeing is a lot more of these lower risk PEs being picked up – which is why it’s a very different scenario maybe from what we would have seen 15-20 years ago, where you were largely picking up the higher risk PEs”, he explains.

Before the new out-patient PE pathway was developed it was felt that there wasn’t a consistent approach within the Health Board towards management of PEs.  A review of patients who had deep vein thromboses (DVTs) showed that 50% of them did not receive any follow-up. “Follow-up is important because, number one, we need to see how patients are recovering but also we need to make decisions around long-term management”, explains Mr Power.

Furthermore, the report of a National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in 2019 that looked at the current status of PE management in the UK, flagged up a number of problems. Some of the key points were:

• PE patients were not being followed up correctly
• There was no assessment of PE severity at the point of diagnosis in many cases
• Many patients with low-risk PEs were suitable for ambulation; whereas 37-49% of patients were suitable for an ambulatory care pathway, only 16.4% actually received this type of care.  Consequently, many patients were unnecessarily hospitalised.

In addition, the information provided at discharge was often inadequate.  “It’s critical that when we discharge a patient from hospital with a PE they are aware of what a bad outcome can look like or what a complication can look like and that they can have access to get immediately back into hospital”, says Mr Power.

In 2020 the British Thoracic Society (BTS) Quality Standards for the Outpatient Management of Pulmonary Embolism were published. The quality standards tackled all the points that had been raised in the NCEPOD report and the team in Swansea used this a prompt to review its own services and a catalyst to develop the new service.

About Kieron Power

Kieron Power is Principal Pharmacist for Thrombosis and Anticoagulation in Swansea Bay University Health Board in South Wales.  His role comprises three elements:

• Thrombosis and Anticoagulation Lead for the health board – a governance role that involves leading on policy and guidance within the Health Board and performance monitoring for hospital-acquired thrombosis rates, venous thromboembolism risk assessments and general anticoagulation prescribing factors.
• Running a weekly thrombosis and anticoagulation specialist clinic on behalf of the consultant haematologists.
• Leading and running the pharmacist-led acute VTE service and follow-up service that operate within the health board

Read and watch the full series on our website or on YouTube.

The two most common forms of venous thromboembolism (VTE) are deep vein thrombosis (DVT) and pulmonary embolism (PE). A pulmonary embolism occurs when a thrombus (clot), usually formed in deep leg vein, travels to the lungs and causes a blockage in the pulmonary blood circulation.  This then leads to pressure developing in the pulmonary circulation. “DVT and PE are actually pathologically similar which is why fundamentally we treat them in the same way, long term, but PE is actually the most serious consequence of VT and has a mortality aspect to it so that’s the condition which people would likely fear more”, explains Mr Power.

In the UK, about 39 to 115 per 100,000 of the population each year will develop a PE and the mortality rate can be up to 30%. However, “what we’ve started to realise in recent times is that not all PEs are the same and actually there’s distinct groups within that bracket”, he says. Some patients present with high-risk PEs, where large thrombi have occluded large vessels, resulting on raised pressure in the right side of the heart and possible haemodynamic instability. Such patients are critically unwell, require hospital admission and may be considered for high-risk procedures such as thrombolysis. “At the other end of the spectrum you get patients with much smaller emboli, which developed within some of the peripheral blood vessels, who may not need that urgent level of care and may actually present with slightly more vague symptoms – often things like pleuritic chest pain – and may well have presented first to their GP, for example, and been treated for things like chest infections”. When there is no improvement on antibiotic treatment such patients may be investigated for PE. “Actually, what we’ve seen is that we shouldn’t consider PE to be one entity – there are different risk groups within that that condition”, he emphasises.

Patients tend to be self-selecting when they experience a pulmonary embolism. Those with large emboli where there is considerable strain on the right ventricle often present with syncope, collapse or significant symptoms of shortness of breath. They will call 999 or present to an Accident and Emergency department and are likely to require hospital admission. They are also likely to be considered for thrombolysis. “We know that thrombolysis has good evidence in terms of reducing mortality but with an associated bleeding risk, so those patients are mainly reviewed by senior clinicians who specialize in acute medicine”, says Mr Power. Typically, they will they receive parenteral anticoagulants before being discharged on an oral anticoagulant once they recover and stabilise.

Patients with lower-risk pulmonary emboli experience milder symptoms and often present to their GP practices. They may be referred to a Same-Day Emergency Care unit (SDEC) where they can be assessed, undergo an urgent computed tomography pulmonary angiogram (CTPA) and then be managed as outpatients.

About Kieron Power

Kieron Power is Principal Pharmacist for Thrombosis and Anticoagulation in Swansea Bay University Health Board in South Wales.  His role comprises three elements:

• Thrombosis and Anticoagulation Lead for the health board – a governance role that involves leading on policy and guidance within the Health Board and performance monitoring for hospital-acquired thrombosis rates, venous thromboembolism risk assessments and general anticoagulation prescribing factors.
• Running a weekly thrombosis and anticoagulation specialist clinic on behalf of the consultant haematologists.
• Leading and running the pharmacist-led acute VTE service and follow-up service that operate within the health board

Read and watch the full series on our website or on YouTube.

The coronavirus pandemic placed additional demands on the VTE service as evidence concerning the use of anticoagulants in covid-19 emerged. Early evidence from China suggested that there might be some mortality benefit associated with the use of heparins due to their anti-inflammatory actions. Mr Power was responsible for leading a group in the Health Board that developed local thrombo-prophylactic policies. Over the past 18 months the policies and guidelines have been developed and modifed in response to new evidence.

“We’ve changed the guideline as the evidence has emerged – especially quite recently where the collaborative trial arms have now published their data…… What we’re actually seeing is that if we use therapeutic doses of low molecular weight heparin in what we classify as ‘moderately-unwell’ covid-19 patients – so these are the patients who were admitted requiring supplemental oxygen but [do] not require intensive oxygen therapy or organ support – ….there does seem to be a trend towards reduction in mortality or escalation to requiring organ support.  So, we’ve been able to shape our guidelines with that and this is what’s now in line with NICE [recommendations]. Conversely, in the critical care arm it seemed that there was no benefit in terms of using therapeutic anticoagulant therapy and in fact there was an increased bleeding risk”, says Mr Power

These findings have given rise to the hypothesis that early use of therapeutic doses of anticoagulant therapy may prevent the progression to disseminated intravascular coagulation (DIC), but the mechanism is still uncertain, he adds.

The case for a pharmacy-managed VTE service

The VTE service at Singleton Hospital expects to see 400-500 new VTE patients compared with about 150 three years ago, says Mr Power.

“One of the things we focused on in terms of benefits is the turnaround time for patients. So, the in the All Party Parliamentary Thrombosis Group report in 2018 they quoted the average figure from a patient being diagnosed with a VTE to the treatment being initiated to the patient [being] discharged as 16 hours. Within our service we’ve measured this and we’re actually 105 minutes – so we’re far below the national average. …..  In patients who could have the same-day scans there’s 137 minutes between the patient attending, having a scan, being seen by us, initiated on treatment and sent home with our treatment in their hand”, he explains.

Such a rapid turnaround depends on ready access to radiology services, he acknowledges. The major benefit of the service is fast turnaround with a safe service and built-in follow up.

“It is an efficient service that allows patients to be managed quickly but safely and then the knowledge that they’re also then part of the service where they’ll have follow-up and all of those treatment decisions will be undertaken under that one umbrella”, he says.

Next steps

With a projected workload of 450-500 patients this year, the service has outgrown its original resources and funding has been requested for additional pharmacists and for additional training resources. However, the pharmacy team could be taking on a diagnostic role in future.

Mr Power says, “We’ve already piloted this on a number of occasions. I’ve done training with the GPs and we’re just waiting on some funding to be able to cement our position there, but I’m pretty optimistic that we’ll then be taking on the assessment and diagnostic role with DVT (deep vein thrombosis) patients –  which is quite exciting”.

Call to action

Mr Power’s message to colleagues is that they should consider developing VTE management services. He says, “It’s primarily drug based, it’s complex and so it definitely requires somebody with specialist knowledge…… It’s one of the most common conditions that we see so if you’re working in health boards where there’s that gap ……  then I urge you to get involved with the area, develop your expertise, get your IP [and] develop your services …. the benefits are absolutely huge.”.

Mr Power adds that pharmacists or pharmacy technicians who are interested in developing VTE services are welcome to get in touch with him.

Read and watch the full series on our website or on YouTube.

One important development was the cancer thrombosis pathway.  This stemmed from the PELICAN (Patients’ Experiences of LIving with CANcer-associated thrombosis) study, led by Professor Simon Noble, in which patients receiving treatment for cancer-associated thrombosis (CAT) were interviewed about their experiences.

Many patients felt that the level of support they received for CAT compared unfavourably with their cancer care. This is a problem because 20% of cancer patients develop a thrombosis, notes Mr Power.

“We thought, “Well, we’ve got a VTE service, we’re seeing cancer patients how can we make this better for them?” and so what we did was we developed a specific cancer-associated thrombosis pathway whereby we had every single cancer thrombosis diagnosis come through our pathway within the health board and we would manage them from initiation to that six-month decision – because with cancer-associated thrombosis six months is generally the minimum duration – and much of our focus was around easing anxieties and improving patient education”, he explains.

When the service was evaluated anxiety scores and knowledge retention improved and patients were generally better informed.

Haematology clinic

A weekly haematology clinic is an integral part of the VTE service. This started as a DOAC (direct-acting oral anticoagulant) initiation clinic, when this process was started in secondary care, recalls Mr Power. Now that this is routinely undertaken in primary care in most of the UK, the clinic has developed to deal with patients with complex anticoagulant or thrombosis needs such as those with VTEs at unusual sites, patients with anti-phospholipid syndrome and those who require complex bridging arrangements, he says

Independent prescribers

Gaining independent prescriber (IP) qualifications has enabled the pharmacy VTE team members to function effectively as independent practitioners, says Mr Power.  In fact, they ran the service for several years before gaining their IP qualifications in 2018.

“I think the single most important thing that developed in terms of our service was that we all gained IP qualifications because it just allowed us to then become independent practitioners and develop the service as we wanted to, whereas prior to that it was quite difficult to make those independent decisions because you were fundamentally relying on somebody else to prescribe the medication for you”, he says.

De-skilling or up-skilling of junior doctors?

When asked whether the pharmacy-managed VTE service risks de-skilling of junior doctors in relation to anti-coagulant prescribing Mr Power argues that the education and guidelines that have been put in place have, in fact, up-skill junior doctors in this area.

“When we came in we identified numerous aspects of VTE care that weren’t in line with evidence or guidance and we’ve been able to improve on those things…….. I don’t feel like we’ve de-skilled the healthcare professionals, I think we’ve upskilled them ….  mainly through our education that we’ve undertaken [and] through the guidelines we’ve developed. ….  I was reflecting on this recently because I think one of the proudest [moments] I have is when I hear junior doctors quoting elements of management that I know that we’ve put into guidelines.  I kind of think, “Well, they weren’t saying those things three or four years ago!” “, says Mr Power.

Read and watch the full series on our website or on YouTube.

The management of VTE is complex because of the number of factors that need to be taken into account.  The first step is the selection of an appropriate anticoagulant and this is not a one-size-fits-all situation. There can be differences in the provoking factors, the locations of the VTE and patient factors such as renal function, weight, and presence of anti-phospholipid syndrome, for example.  The next important decision is about the duration of treatment. “We know now that recurrence rates are higher than we maybe previously thought and so far more now we’re assessing  patients, even after first-time events, for lifelong anticoagulant therapy”, says Mr Power. The third ‘complexity’ is concerned with long-term risks of complications, in particular post-thrombotic syndrome which affects some 30% of patients with VTE.

“Post thrombotic syndrome …..  is essentially where patients have the long term symptoms of VTE despite them not having recurrent thrombotic episodes. So patients will often have long-term leg swelling, cramping, pain. The difficulty with it is that there is no known effective treatment or cure for it and so much of it comes down to patient expectation management and maybe things like stockings that can help to support them”, explains Mr Power.

Similarly, pulmonary embolism (PE) can be associated with long-term complications. “One of the long-term complications of PE is CTEPH or chronic thromboembolic pulmonary hypertension. So, again, this can be quite a disabling condition [in which] you have chronic clots within your lung developing high pressures within the right side of your heart and ….. a lot of these patients have long-term dyspnoea and their performance in life is greatly reduced”, he says.

Direct-acting oral anticoagulants (DOACs)

From the patient’s perspective the introduction of DOACs has made anticoagulation a more straightforward process with fewer dietary impacts and interactions with other medication. From the pharmacist’s viewpoint, now that less time has to be spent on anticoagulant dosing and monitoring there is more time to spend on other important aspects of patient management. Furthermore, the improved safety profile of the DOACs has been important. “The bleeding data, especially in long-term patients, is very positive and I think that now –  because we’re far more comfortable with the idea of using long-term anticoagulant therapy – we are seeing far more people with first unprovoked VTE going on to receive lifelong anticoagulant therapy whereas I’m not so sure we would be as comfortable with warfarin”, says Mr Power. Nevertheless, there are nuances in treatment and DOACs are not suitable for everyone. “We need individuals to be able to identify the correct patients and …… I can’t see why that can’t be a pharmacist”, he adds.

A typical VTE patient swill be diagnosed by a physician and referred to the pharmacy team on the same day. The initial consultation is concerned with the selection of the correct anticoagulant regimen. At subsequent reviews the patient’s compliance with and tolerance of the treatment is assessed and additional investigations are arranged if necessary. At the three-month review the decision is made between lifelong treatment or discontinuation. Patients for whom lifelong treatment is recommended are then referred to their GP for ongoing management.

Read and watch the full series on our website or on YouTube.

Mr Power is responsible for leading, directing and overseeing the ongoing development of the VTE service at Singleton Hospital. He also has a hands-on role in the day-to-day operation of the service and runs a weekly haematology clinic for review of patients with complex thrombosis and anticoagulation issues.

The VTE service has grown steadily since pharmacists were first asked to assist with warfarin dosing for the ambulatory VTE service. This involved supporting patients “to get into [the therapeutic] range before being referred on to warfarin dosing clinics”, explains Mr Power. As warfarin usage diminished and was replaced by direct-acting oral anticoagulants (DOACs) the pharmacy team began to take a more prominent role in VTE management – and the service has continued to grow and develop.

“Over the past couple of years we’ve evolved our service so that we’re now the primary clinicians who look after VTE in the health board. What I mean by that is once the patient ‘s been diagnosed with a VTE, they get passed to us for a same day appointment where we will initiate therapy and the patient then will be under our care for the duration of their management until we make a decision at the at 3-6 month point and then we either stop the anticoagulant therapy or refer them on to primary care”, say Mr Power.

Whereas many pharmacy-led anticoagulation services are focused on stroke prevention in patients with atrial fibrillation (AF), the service at Singleton Hospital is VTE-focused. Mr Power attributes this to its historical origins and, more recently, to the complexity of VTE management. “I think there’s far more complexity in VTE management than there is in AF management when it comes to anticoagulant therapy – mainly because I think there’s a lot of supporting algorithms in terms of AF management whereas [in] VTE there’s a lot more variability in the type of patients you see, there‘s a lot more decision points t o undertake as you go along and, as such, it became an area that I thought worked very well with pharmacist independent prescribers – and as our interest grew the service grew with it”, he says.

VTE is estimated to affect one-two patients per 1000 patients each year in Europe. There are immediate risks and there can also be long-term complications.

“I think the complexity of management is also far more than people realise. It’s not a case of where we used think maybe we would just treat people for three to six months with anticoagulant therapy and that would be that. We’re now far more interested in long-term risks of recurrence [and] long-term complications, explains Mr Power.

One of the main benefits of the service for patients is consistency of decision-making and management, he says. “There are three of us currently who run the service as independent prescribers; most patients will see one of the three of us…….. we have a very tight system whereby all of these processes are undertaken and so that they can rest assured that once they’re under our service they will have all of those management decisions undertaken under one roof.

Read and watch the full series on our website or on YouTube.