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
Other diagnostic factors
- cough
- fever
- haemoptysis
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 long-duration 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
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
Emerging tests
- biomarkers
- point-of-care D-dimer testing
- D-dimer adjusted to clinical probability
- magnetic resonance angiography (MRA)
Treatment algorithm
PE suspected: haemodynamically unstable AND/OR hypoxaemic
PE confirmed (on echocardiography or CTPA); haemodynamically unstable
PE confirmed (on CTPA) or highly suspected (Wells >4 or positive D-dimer); haemodynamically stable
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
JB is deputy medical director RCP Invited Service Reviews, and speaker at National Society (eg., BTS), Primary Care Respiratory Society, and Society Cardiothoracic Surgeons meetings.
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
Consultant Respiratory Physician
Glenfield Hospital
Leicester
UK
Disclosures
OU declares that she has no competing interests.
Claire Vella
Consultant Respiratory Physician
Glenfield Hospital
Leicester
UK
Disclosures
CV declares that she has no competing interests.
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.
References
Key articles
Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020 Jan 21;41(4):543-603.Full text Abstract
National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. Aug 2023 [internet publication].Full text
Howard LSGE, Barden S, Condliffe R, et al. British Thoracic Society guideline for the initial outpatient management of pulmonary embolism (PE). Thorax. 2018 Jul;73 (Suppl 2):ii1-29.Full text Abstract
Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic therapy for VTE disease: second update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160(6):e545-608.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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