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
- 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
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
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
Treatment algorithm
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
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.
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.
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