What is the best course of action for a patient with a history of pulmonary embolism (PE) presenting with burning chest pain?

Management of Burning Chest Pain in a Patient with History of Pulmonary Embolism

For a patient with a history of pulmonary embolism presenting with burning chest pain, immediate diagnostic evaluation is necessary, including assessment of clinical probability, D-dimer testing if indicated, and appropriate imaging based on risk stratification. 1, 2

Initial Assessment

• Assess clinical probability of PE by evaluating risk factors and clinical presentation 1
• Consider whether another diagnosis is unlikely (chest radiograph and ECG are helpful) and whether major risk factors are present (recent immobility, surgery, trauma, pregnancy, medical illness, or previous VTE) 1
• Record respiratory rate, as most patients with PE are breathless and/or tachypneic (>20/min) 1
• Obtain chest radiography, ECG, and arterial gas measurements for all patients with suspected PE 1
• In the absence of tachypnea (>20/min), pleuritic pain, and arterial hypoxemia, a diagnosis of PE can be excluded 1

Diagnostic Algorithm

Step 1: Clinical Probability Assessment

• Low probability: No risk factors or alternative diagnosis likely
• Intermediate probability: Either risk factors present or alternative diagnosis unlikely
• High probability: Both risk factors present and alternative diagnosis unlikely 1

Step 2: D-dimer Testing

• D-dimer testing should be performed if clinical probability is low or intermediate 1
• Do not perform D-dimer if:
  • An alternative diagnosis is highly likely
  • Clinical probability is high
  • Massive PE is suspected 1
• Use age-adjusted D-dimer thresholds (age × 10 ng/mL) for patients older than 50 years 1
• A negative D-dimer result with validated tests can exclude PE in appropriate clinical scenarios 1

Step 3: Imaging

• For patients with history of PE presenting with chest pain, leg vein imaging should be performed as a first-line investigation 1
• Consider lower-extremity venous ultrasonography before CT, especially in patients with lower-extremity symptoms 1
• If D-dimer is positive or not performed (high clinical probability), proceed with appropriate imaging:
  • CTPA (CT pulmonary angiography) is preferred in patients with abnormal chest radiograph or chronic cardiorespiratory disease 1
  • V/Q scanning can be considered for patients with multiple previous CTs to reduce radiation exposure 1

Management Considerations

• If PE is confirmed or highly suspected, initiate anticoagulation promptly 1
• For hemodynamically stable patients (systolic BP ≥90 mmHg), direct oral anticoagulants (apixaban, edoxaban, rivaroxaban, or dabigatran) are preferred over warfarin 2
• For patients with systolic BP <90 mmHg, consider thrombolytic therapy 2
• Duration of anticoagulation depends on clinical circumstances:
  • For PE secondary to transient risk factors: 3 months 3, 4
  • For first episode of idiopathic PE: 6-12 months 3
  • For recurrent PE or persistent risk factors: indefinite anticoagulation 3, 4

Special Considerations

• Be aware that PE can mimic other conditions, including STEMI on ECG 5
• For patients with history of multiple CTs for PE, consider alternative diagnostic approaches to reduce radiation exposure 1
• Patients with persistent or recurrent dyspnea after PE should be evaluated for chronic thromboembolic pulmonary hypertension (CTEPH) 4
• Consider outpatient treatment if the patient is not unduly breathless, has no medical or social contraindications, and there is an efficient protocol in place 1

Pitfalls to Avoid

• Avoid overdiagnosis or underdiagnosis of PE, as both are common in clinical practice 1
• Do not rely solely on clinical features for patients with indeterminate lung scans; further imaging is required 1
• Recognize that burning chest pain may represent PE but could also indicate other diagnoses; maintain a broad differential 6
• Do not automatically assume recurrent PE in a patient with history of PE presenting with chest pain; consider alternative diagnoses 1