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Pulmonary embolism

Última revisión: 15 Sep 2025
Última actualización: 05 Jun 2025

Resumen

Definition

History and exam

Key diagnostic factors

  • chest pain
  • dyspnea
  • tachypnea
  • presyncope or syncope
  • hypotension (systolic BP <90 mmHg)
Full details

Other diagnostic factors

  • feeling of apprehension
  • cough
  • tachycardia
  • fever
  • unilateral swelling/tenderness of calf
  • hemoptysis
  • elevated jugular venous pressure
  • sternal heave
  • accentuated pulmonary component of S2
Full details

Risk factors

  • diagnosis of deep vein thrombosis (DVT)
  • major surgery within the preceding 3 months
  • medical hospitalization within the preceding 2 months
  • active cancer
  • previous venous thromboembolic event
  • recent trauma or fracture
  • increasing age
  • pregnancy and postpartum
  • varicose veins
  • paralysis of the lower extremities
  • hereditary thrombophilias
  • factor V Leiden mutation
  • prothrombin G20210A mutation
  • protein C and protein S deficiency
  • antithrombin deficiency
  • antiphospholipid antibody syndrome
  • medical comorbidity
  • use of specific drugs
  • obesity (BMI ≥29 kg/m²)
  • cigarette smoking
  • recent long-duration travel
  • family history of venous thromboembolic (VTE)
  • central venous catheterization
Full details

Diagnostic tests

1st tests to order

  • Pulmonary Embolism Rule-Out Criteria (PERC)
  • Wells criteria/Geneva score/YEARS criteria
  • D-dimer test
  • multiple-detector computed tomographic pulmonary angiography (CTPA)
  • ventilation-perfusion (V/Q) scan
  • coagulation studies
  • BUN and creatinine, hepatic function tests
  • CBC
Full details

Tests to consider

  • Point-of-care ultrasound (POCUS)
  • chest x-ray
  • magnetic resonance angiography (MRA)
  • pulmonary angiography
  • transthoracic echocardiography (TTE)
  • electrocardiography (ECG)
  • arterial blood gasses (ABG)
  • thrombophilia screen
  • ultrasonography
  • troponin
Full details

Treatment algorithm

ACUTE

high risk (massive) PE or high clinical probability of PE with shock or hypotension (i.e., systolic BP <90 mmHg), no contraindication to anticoagulation or thrombolysis

high risk or intermediate-high risk, contraindication to anticoagulation or thrombolysis

intermediate-high risk PESI/sPESI score, no contraindication to anticoagulation or thrombolysis

intermediate-low risk or low risk PESI/sPESI score, no contraindication to anticoagulation

intermediate-low risk or low risk PESI/sPESI score, contraindication to anticoagulation

ONGOING

confirmed PE: provoked

confirmed PE: unprovoked

confirmed PE: pregnant

confirmed PE: cancer-associated

confirmed PE: recurrent PE while on anticoagulation

Contributors

Authors

Scott Stevens, MD

Director

Thrombosis Clinic

Intermountain Medical Center

Murray

Professor of Medicine

Department of Medicine

Intermountain Healthcare and University of Utah

Salt Lake City

UT

Disclosures

SS declares that he has no competing interests.

Scott C. Woller, MD

Director

Thrombosis Clinic

Intermountain Medical Center

Murray

Professor

Department of Medicine

Intermountain Healthcare and University of Utah

Salt Lake City

UT

Disclosures

SCW declares that he is expecting to receive funding of an investigator initiated grant from Janssen Pharmaceuticals to Intermountain Health with no direct compensation to himself for research in the sum of $500,000 in 2024.

Gabriel V. Fontaine, PharmD, MBA, BCPS

Clinical Pharmacy Manager

Critical Care and Emergency Medicine

Advanced Clinical Pharmacist

Neuroscience Critical Care

Intermountain Medical Center

Murray

UT

Disclosures

GVF has received consulting fees and honoraria from AstraZeneca, Chiesi, and Anticoagulation Forum.

Acknowledgements

Dr Scott M. Stevens, Dr Scott C. Woller, and Dr Gabriel V. Fontaine would like to gratefully acknowledge Drs Geno Merli, Luis H. Eraso, Taki Galanis, Geoffrey Ouma, Miguel Angel de Gregorio, Alicia Laborda, and Seth W. Clemens, previous contributors to this topic.

Divulgaciones

GM has received grants or research support from BMS, J&J, Sanofi-Aventis, Portola, and Janssen; he has served as a Scientific Consultant for BMS, J&J, and Sanofi-Aventis. LHE, TG, GO, MAG, AL, and SWC declare that they have no competing interests.

Revisores por pares

Keith Wille, MD, MSPH

Associate Professor of Medicine

University of Alabama at Birmingham

Birmingham

AL

Divulgaciones

KW declares that he has no competing interests.

John R. Charpie, MD, PhD

Associate Professor of Pediatrics

Medical Director

Pediatric Cardiothoracic Intensive Care Unit

University of Michigan Congenital Heart Center

C.S. Mott Children's Hospital

Ann Arbor

MI

Divulgaciones

JRC declares that he has no competing interests.

Sanjeev Wasson, MD

Advanced Clinical Fellow

Cleveland Clinic Foundation

Cleveland

OH

Divulgaciones

SW declares that he has no competing interests.

David Jimenez, MD, PhD

Respiratory Physician and Associate Professor

Ramón y Cajal Hospital and Alcalá de Henares University

Respiratory Department and Medicine Department

Madrid

Spain

Divulgaciones

DJ has received consulting fees from Boehringer Ingelheim, Bayer, Leo-Pharm, and Rovi, and lecture fees from Sanofi Aventis.

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Referencias

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Artículos principales

Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020 Jan 21;41(4):543-603.Texto completo

Stevens SM, Woller SC, Baumann Kreuziger L, et al. Antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report. 2021 Dec;160(6):e545-608.Texto completo  Resumen

American College of Radiology. ACR Appropriateness Criteria®: suspected pulmonary embolism. 2022 [internet publication].Texto completo

Bates SM, Rajasekhar A, Middeldorp S, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. Blood Adv. 2018 Nov 27;2(22):3317-59.Texto completo  Resumen

Stevens SM, Woller SC, Baumann Kreuziger L, et al. Antithrombotic therapy for VTE disease: compendium and review of CHEST guidelines 2012-2021. Chest. 2024 Aug;166(2):388-404.Texto completo  Resumen

Lyman GH, Carrier M, Ay C, et al. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv. 2021 Feb 23;5(4):927-74.Texto completo  Resumen

Artículos de referencia

Una lista completa de las fuentes a las que se hace referencia en este tema está disponible para los usuarios con acceso a todo BMJ Best Practice.
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