Pulmonary embolism

Last reviewed: 4 Jun 2022
Last updated: 10 Mar 2022

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
Full details

Other diagnostic factors

  • cough
  • fever
  • haemoptysis
Full details

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
Full details

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

INITIAL

PE suspected: haemodynamically unstable AND/OR hypoxaemic

ACUTE

PE confirmed (on echocardiography or CTPA); haemodynamically unstable

PE confirmed (on CTPA) or highly suspected (Wells >4 or positive D-dimer); haemodynamically stable

ONGOING

confirmed first episode of PE (started on acute-phase anticoagulation)

recurrent PE despite adequate anticoagulation therapy

Contributors

Expert advisers

Jonathan Bennett, MD

Honorary Professor of Respiratory Sciences

University of Leicester

Respiratory Consultant

Glenfield Hospital

Leicester

UK

Biography

Chair British Thoracic Society (BTS), Deputy Medical Director RCP Invited service Reviews; Speaker at National Society Meetings (e.g., BTS), Primary Care respiratory Society, and Society Cardiothoracic Surgeons. None of these conflict with the BMJ expert advisor role.

Disclosures

JB declares that he has no competing interests.

Richard Russell, MBBS, PhD, MRCP

Specialty Registrar in Respiratory Medicine

Glenfield Hospital

Leicester

UK

Disclosures

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

Onyeka Umerah,

Respiratory registrar

Glenfield Hospital

Leicester

UK

Disclosures

Claire Vella,

Clinical fellow in lung cancer

Glenfield Hospital

Leicester

UK

Disclosures

Acknowledgements,

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 reviewers

Catherine Free,

Consultant Respiratory Physician

Medical Director

George Eliot Hospital NHS Trust

Nuneaton

UK

Disclosures

CF declares that she has no competing interests.

Editors

Annabel Sidwell,

Section Editor, BMJ Best Practice

Disclosures

AS declares that she has no competing interests.

Jo Haynes,

Head of Editorial, BMJ Knowledge Centre

Disclosures

JH declares that she has no competing interests.

Julie Costello,

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Adam Mitchell,

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

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