Last reviewed: 30 Oct 2020
Last updated: 17 Feb 2020

Summary

Definition

History and exam

Key diagnostic factors

  • dyspnoea
  • chest pain
  • signs of concurrent deep vein thrombosis (DVT)
  • risk factors
  • hypoxaemia
  • failure to meet Pulmonary Embolism Rule-out Criteria (the PERC rule)
  • positive Wells (or Geneva) score 
  • signs of haemodynamic instability or severely reduced haemodynamic reserve

Risk factors

  • increasing age
  • diagnosis of deep vein thrombosis (DVT)
  • obesity (BMI ≥29 kg/m²)
  • surgery within the last 2 months
  • bed rest >5 days
  • previous venous thromboembolic event
  • family history of venous thromboembolism (VTE)
  • active malignancy
  • cigarette smoking
  • chronic obstructive pulmonary disease (COPD)
  • recent trauma or fracture
  • congestive heart failure (CHF)
  • central venous catheterisation
  • pregnancy/postnatal period
  • varicose veins
  • recent air travel
  • history of spontaneous abortion
  • recent acute myocardial infarction
  • sepsis
  • recent blood transfusion
  • combined hormonal contraception
  • oral hormone replacement therapy (HRT)
  • paralysis of the lower extremities
  • inflammatory bowel disease
  • nephrotic syndrome
  • Behcet's disease
  • homocysteinaemia
  • Philadelphia-negative myeloproliferative neoplasms
  • factor V Leiden mutation
  • prothrombin G20210A mutation
  • antithrombin deficiency
  • protein C deficiency
  • protein S deficiency
  • antiphospholipid antibody syndrome

Diagnostic investigations

1st investigations to order

  • computed tomographic pulmonary angiography (CTPA)
  • echocardiography
  • D-dimer
  • full blood count
  • ECG
  • urea and electrolytes
  • coagulation studies
  • liver function tests
Full details

Investigations to consider

  • arterial blood gas (ABG)
  • chest x-ray (CXR)
  • lower limb compression venous ultrasound
  • cardiac biomarker
  • ventilation-perfusion (V/Q) scan
  • further investigation for unprovoked PE
Full details

Emerging tests

  • biomarkers
  • point-of-care D-dimer testing
  • D-dimer adjusted to clinical probability
  • magnetic resonance angiography (MRA)
Full details

Treatment algorithm

Contributors

Expert advisersVIEW ALL

Honorary Professor of Respiratory Sciences

University of Leicester

Respiratory Consultant

Glenfield Hospital

Leicester

UK

Disclosures

JB is Chair, British Thoracic Society (unpaid). JB declares that he has no competing interests.

Specialty Registrar in Respiratory Medicine

Glenfield Hospital

Leicester

UK

Disclosures

RJR received sponsorship from AstraZeneca to attend a conference, May 2018 (covering travel, accommodation, and conference fee).

Respiratory registrar

Glenfield Hospital

Leicester

UK

Disclosures

Clinical fellow in lung cancer

Glenfield Hospital

Leicester

UK

Disclosures

BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:

Scott M. Stevens MD

Director

Thrombosis Clinic

Intermountain Medical Center

Murray

UT

Professor of Medicine

Department of Internal Medicine

University of Utah

Salt Lake City

UT 

Scott C. Woller MD

Director

Thrombosis Clinic

Intermountain Medical Center

Murray

UT

Professor of Medicine

University of Utah

Salt Lake City

UT

Gabriel V. Fontaine PharmD, BCPS

Clinical Coordinator

Critical Care Pharmacy

Advanced Clinical Pharmacist

Neuroscience Critical Care

Intermountain Medical Center

Murray

UT 

Disclosures

SMS is an investigator for two investigator-initiated clinical trials for which his institution receives funds from Bristol-Myers Squibb to enrol patients. SCW holds two investigator-initiated grants from Bristol-Myers Squibb/Pfizer paid to his employer Intermountain Healthcare for which he receives no compensation. He has been invited to serve as co-chair of the American College of Chest Physicians guideline on antithrombotic therapy for venous thromboembolic disease (AT11) and serves as an invited panelist for the US Centers for Disease Control and Prevention venous thromboembolism risk assessment model systematic review and guidance panel. GVF receives consulting fees and honoraria from Portola Pharmaceuticals for clinical consulting and speaking engagements.

Peer reviewersVIEW ALL

Consultant Respiratory Physician

Medical Director

George Eliot Hospital NHS Trust 

Nuneaton

UK

Disclosures

CF declares that she has no competing interests.

Section Editor, BMJ Best Practice

Disclosures

AS declares that she has no competing interests.

Head of Editorial, BMJ Knowledge Centre

Disclosures

JH declares that she has no competing interests.

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

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