Post-Test Questions

Article 2 (92–98)

1. What percentage of patients with pulmonary embolism will die within a year of diagnosis?

   • 1%.

   • 5%.

   • 15–20%.

   • 60%.

2. The “post pulmonary embolism” syndrome occurs in what percentage of patients?

   • 0%.

   • 4%.

   • >25%.

3. The highest rates of VTE are seen in which patient population?

   • Peripartum patients.

   • Patients with metastatic malignancies.

   • Morbidly obese patients.

   • Patients with rheumatologic disorders.

   Article 3 (99–104)

4. Given high recurrence rates of VTE among patients with cancer, the American Society for Clinical Oncology (ASCO) recommends a minimum treatment period with anticoagulant therapy for an initial VTE of:

   • 3 months.

   • 6 months.

   • 6 months, with the possibility of continuation depending on other clinical risk factors.

   • There is no guideline to help determine the appropriate length of therapy.

5. A 35-year-old woman has a history of pulmonary embolism diagnosed at age 30 years, 3 months after starting third-generation combined hormonal contraception. She received 6 months of anticoagulant therapy. She calls for hematology appointment because she has a positive urine pregnancy test. Pregnancy is confirmed by a positive Beta-HCG. How should this patient be managed?

   • Careful monitoring for VTE symptoms during pregnancy and postpartum pharmacologic thromboprophylaxis.

   • Careful monitoring for VTE symptoms during pregnancy and postpartum pharmacologic thromboprophylaxis only if she delivers via C-section.

   • Pharmacologic thromboprophylaxis during pregnancy and careful VTE surveillance in the postpartum period.

   • Pharmacologic thromboprophylaxis during pregnancy and postpartum period.

6. A 27-year-old woman is diagnosed of a PE after she experienced a near-syncopal episode after a 5-hour flight. She is taking combined oral contraceptives (COC) for the past 5 years. There is no family history of VTE. She is screened for thrombophilia and is found to have triple positivity antiphospholipid antibodies (aPL). She is treated with a direct oral anticoagulant (DOAC) rivaroxaban and completes 12 months of anticoagulation; aPL is retested while of anticoagulation for 1 month confirming previous results. D-dimer test is negative 1 month after discontinuation of anticoagulation. She is now on aspirin 81 mg and off COC. What should you do next?

   • Restart anticoagulation therapy with warfarin to target an International Normalization Ratio (INR) of 2–3.

   • Continue aspirin 81 mg.

   • Restart anticoagulation therapy with rivaroxaban 20 mg.

   • Continue holding anticoagulation in a daily basis and use anticoagulation in high-risk situations such as pregnancy, postpartum, surgery, and trauma or if she restarts combined hormonal contraception and during long-haul flights.

   Article 4 (105–107)

7. When compared to anticoagulation alone, adjunctive use of a retrievable IVC filter along with anticoagulation in patients who are at high risk for recurrent PE results in:

   • Increased incidence of PE at 6 months.

   • Decreased incidence of PE at 6 months.

   • Increased incidence of DVT at 6 months.

   • Decreased incidence of DVT at 6 months.

   • No change in incidence of PE or DVT at 6 months.

8. Which of the following is an adverse effect of a longterm indwelling permanent IVC filter?

   • Increased incidence of DVT.

   • Increased incidence of postthrombotic syndrome.

   • Increased mortality rate.

   • A and B.

   • A, B, and C.

9. How has the use of novel oral anticoagulants (NOACs) affected the rate of recurrent PE compared to traditional methods of anticoagulation?

   • The rate of recurrent PE has decreased.

   • The rate of recurrent PE has not changed.

   • The rate of recurrent PE has increased.

   • This has not been studied.

   Article 5 (108–115)

10. Which of the following is correct regarding the stratification of pulmonary embolism (PE)?

    • Low-risk PE patients present with any cardiac or hemodynamic compromise and are typically identified with radiologic imaging alone.

    • Submassive PE can be defined by imaging only (echocardiogram or CT).

    • Massive PE comprises patients with cardiopulmonary failure and/or hemodynamic compromise, which often requires pressor or respiratory support.

    • All of the above are correct.

11. What is the 1-month mortality rate in patients with pulmonary embolism and hemodynamic compromise?

    • 0–10%.

    • 10–20%.

    • 30–40%.

    • 50–60%.

    • 80–90%.

12. Which of the following is correct regarding the treatment for massive pulmonary embolism?

    • Surgical thrombectomy requires putting the patient on cardiopulmonary bypass.

    • Systemic thrombolysis has not been shown to improve overall mortality rates.

    • The American College of Chest Physicians 2016 guidelines recommend the use of catheter-directed therapy in massive PE in patients with (1) a high bleeding risk, (2) failed systemic thrombolysis, or (3) shock that is likely to cause death before systemic thrombolysis can take effect (e.g., within hours), if local expertise is available.

    • All of the above are correct.

    Article 6 (116–121)

13. A 48-year-old woman presents with shortness of breath with no history of cardiac arrest. Her blood pressure is stable; however, PESI score is estimated at class III with laboratory demonstrating increased troponins. Echocardiogram suggests right ventricular strain. What is the patient's risk of early mortality based on European Society of Cardiology Guidelines?

    • High.

    • High intermediate.

    • Intermediate low.

    • Low.

14. In which category of pulmonary embolism (PE) is fibrinolytic therapy not recommended?

    • Massive PE.

    • Submassive PE.

    • Low risk.

    • Fibrinolytic therapy is recommended in all of the above scenarios.

15. Which initial imaging modality is mostly rated a 9 by the American College of Radiology Appropriateness Criteria in intermediate probability patient with positive D-dimer.

    • Chest radiograph.

    • Technecium-99m ventilation perfusion (V/Q) scan.

    • Ultrasound duplex Doppler.

    • Noncontrast chest CT.

    • Chest MRI with contrast.

    Article 7 (122–128)

16. Which of the following is true of the three prospective trials (ULTIMA, SEATTLE 2, and PERFECT) regarding the use of catheter-directed thrombolysis in submassive pulmonary embolism?

    • Each had several methodological limitations, which has made it difficult for catheter-directed thrombolysis to become a widely accepted treatment option.

    • Each demonstrated a significant mortality benefit of catheter-directed thrombolysis over systemic thrombolytic administration.

    • Each demonstrated a statistically significant decrease in the risk of major hemorrhage utilizing catheter-directed thrombolysis as compared to other therapies.

    • All were double-blinded, randomized controlled trials.

17. As compared with systemic thrombolytic administration, catheter-directed thrombolysis

    • Has been shown to provide a significant mortality benefit over both systemic thrombolytic administration and therapeutic anticoagulation alone.

    • Has the potential to offer equally effective thrombolysis with lower overall dose of thrombolytics.

    • Is clearly associated with increased risk of hemorrhage and increased periprocedural mortality.

    • Should be reserved for patients with massive pulmonary embolism, as the risks of procedure may far outweigh the benefits in patients without imminent massive physiology.

18. Which of the following is a true statement?

    • The current risk stratification guidelines clearly predict which patients with acute pulmonary embolism will do well with anticoagulation alone, and which will require therapeutic escalation.

    • The standard dose of thrombolytics with systemic administration is equivalent to that typically used in catheter-directed thrombolysis.

    • Ultrasound-assisted catheters have been shown to offer superior efficacy over standard thrombolytic catheters.

    • In acute pulmonary embolism, local hemodynamic alterations result in a large fraction of systemically administered thrombolytics to be delivered to the thrombus.

    • None of the above statements are true.

    Article 8 (129–135)

19. Which of the following devices has a black-box warning regarding its use for treating acute PE?

    • Aspirex.

    • Inari FlowTriever.

    • AngioJet.

    • AngioVac.

20. Which of the following are important preprocedural considerations?

    • Considering consultation with an anesthesia team for their availability during the case.

    • Obtaining an ECG to determine if the patient has left bundle branch block.

    • Obtaining a preprocedure ultrasound of the access vessel.

    • All of the above.

21. Prior to performing catheter-directed pulmonary angiography in patients with acute PE, which of the following must be evaluated?

    • Presence of right heart strain.

    • Whether or not the patient is allergic to contrast dye.

    • Pulmonary artery pressures transduced via catheter or sheath.

    • All of the above.

    Article 9 (136–142)

22. The incidence of pulmonary hypertension as a result of chronic thromboembolic disease is:

    • Not related to acute pulmonary embolism.

    • A very rare condition – less than 1,000 cases annually in USA.

    • Probably in the range of 5% after acute pulmonary embolism.

    • Well established.

23. What is the best initial screening test for pulmonary hypertension?

    • Transthoracic echocardiography.

    • Ventilation – Perfusion scan.

    • Chest X-ray.

    • Clinical examination.

24. After the diagnosis of pulmonary hypertension what investigations are used to differentiate thromboembolic pulmonary hypertension from other cause of pulmonary hypertension?

    • Chest X-ray.

    • Exercise testing.Exercise testing.Exercise testing.Exercise testing.

    • Clinical examination.

    • Lung scan and then pulmonary angiography.

25. What are the results of pulmonary enterectomy?

    • Complete resolution of symptoms cannot be expected.

    • Residual pulmonary hypertension is common.

    • The mortality at an experienced center is in the range of 2%.

    • Recurrence is common.