Last reviewed:September 2019
Last updated:July  2018

Summary

Definition

History and exam

Key diagnostic factors

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

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

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 catheterization
  • pregnancy/postpartum 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 disease
  • homocysteinemia
  • 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

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

Investigations to consider

  • chest x-ray (CXR)
  • magnetic resonance (MR) angiography
  • pulmonary angiography
  • electrocardiography (ECG)
  • arterial blood gases (ABG)
  • thrombophilia screen
  • ultrasonography
Full details

Emerging tests

  • brain natriuretic peptide (BNP), N-terminal proBNP (NT-proBNP), heart-type fatty acid-binding protein (H-FABP)
Full details

Treatment algorithm

Contributors

Director

Thrombosis Clinic

Intermountain Medical Center

Murray

UT

Professor of Medicine

Department of Internal Medicine

University of Utah

Salt Lake City

UT

Disclosures

SMS is an investigator for two investigator-initiated clinical trials for which his institution receives funds from Bristol-Myers Squibb to enroll patients.

Director

Thrombosis Clinic

Intermountain Medical Center

Murray

UT

Professor of Medicine

University of Utah

Salt Lake City

UT

Disclosures

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.

Clinical Coordinator

Critical Care Pharmacy

Advanced Clinical Pharmacist

Neuroscience Critical Care

Intermountain Medical Center

Murray

UT

Disclosures

GVF receives consulting fees and honoraria from Portola Pharmaceuticals for clinical consulting and speaking engagements.

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

Peer reviewersVIEW ALL

Associate Professor of Medicine

University of Alabama at Birmingham

Birmingham

AL

Disclosures

KW declares that he has no competing interests.

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

Disclosures

JRC declares that he has no competing interests.

Advanced Clinical Fellow

Cleveland Clinic Foundation

Cleveland

OH

Disclosures

SW declares that he has no competing interests.

Respiratory Physician and Associate Professor

Ramón y Cajal Hospital and Alcalá de Henares University

Respiratory Department and Medicine Department

Madrid

Spain

Disclosures

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

Use of this content is subject to our disclaimer