Last reviewed: 30 Jun 2021
Last updated: 26 Feb 2021

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

  • 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
  • paralysis of the lower extremities
  • 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-distance air travel
  • family history of venous thromboembolism (VTE)
  • central venous catheterization

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, hepatic function tests
  • CBC
  • Pulmonary Embolism Rule-Out Criteria (PERC)
  • D-dimer test

Investigations to consider

  • chest x-ray
  • magnetic resonance (MR) angiography
  • pulmonary angiography
  • electrocardiography (ECG)
  • arterial blood gases (ABG)
  • thrombophilia screen
  • ultrasonography
  • YEARS criteria
  • troponin

Treatment algorithm

Contributors

Authors

Scott Stevens, MD

Director

Thrombosis Clinic

Intermountain Medical Center

Murray

UT

Professor of Medicine

Department of Medicine

Intermountain Healthcare and University of Utah

Salt Lake City

UT

Disclosures

SS is an unpaid panel co-chair for the American College of Chest Physicians, evidence-based guideline for management of venous thromboembolism. SS was co-investigator for an investigator-initiated clinical trial of apixaban, which was funded by Pfizer/BMS and concluded less than 36 months ago. This activity produces no personal income, but funds were paid to his institution.

Scott C. Woller, MD

Director

Thrombosis Clinic

Intermountain Medical Center

Murray

UT

Professor

Department of Medicine

Intermountain Healthcare and University of Utah

Salt Lake City

UT

Disclosures

SCW serves as co-chair for the American College of Chest Physicians' chapter on the treatment of venous thromboembolic disease

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 financial compensation for speaking engagements and clinical consultation from Portola Pharmaceuticals, the manufacturer of Andexxa, as well as Bevyxxa and Janssen, the manufacturer of Xarelto.

Acknowledgements

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.

Disclosures

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.

Peer reviewers

Keith Wille, MD, MSPH

Associate Professor of Medicine

University of Alabama at Birmingham

Birmingham

AL

Disclosures

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

Disclosures

JRC declares that he has no competing interests.

Sanjeev Wasson, MD

Advanced Clinical Fellow

Cleveland Clinic Foundation

Cleveland

OH

Disclosures

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

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