From the Guidelines
Pulmonary embolism (PE) presents with symptoms including sudden-onset dyspnea, chest pain (often pleuritic), cough, hemoptysis, syncope, and tachycardia, and signs may include tachypnea, hypoxemia, fever, leg swelling, and in severe cases, hypotension or shock. When taking a history, inquire about risk factors such as recent immobilization, surgery, cancer, pregnancy, oral contraceptive use, family history of clotting disorders, and previous venous thromboembolism 1. During physical examination, assess vital signs, oxygen saturation, respiratory effort, heart sounds, and examine the legs for signs of deep vein thrombosis like swelling, warmth, or tenderness.
Diagnostic Workup
The diagnostic workup includes:
- D-dimer testing (for low-risk patients)
- CT pulmonary angiography (gold standard) 1
- Ventilation-perfusion scan (for patients who cannot receive contrast)
- Echocardiography to assess right heart strain
Management
Management begins with oxygen supplementation and hemodynamic support as needed. Anticoagulation is the cornerstone of treatment, typically starting with heparin (unfractionated or low-molecular-weight) and transitioning to oral anticoagulants like direct oral anticoagulants (apixaban, rivaroxaban) or warfarin for 3-6 months 1. For massive PE with hemodynamic instability, thrombolytic therapy or mechanical thrombectomy may be considered. Risk stratification using tools like PESI score helps determine whether outpatient management is appropriate or if hospitalization is required. Inferior vena cava filters are reserved for patients with contraindications to anticoagulation or recurrent PE despite adequate anticoagulation.
Key Considerations
- In patients with high suspicion of PE and no contraindications, consider initiating early anticoagulation while waiting for imaging results 1
- Use recommended, validated diagnostic algorithms for PE, including standardized assessment of (pre-test) clinical probability and D-dimer testing 1
- Prefer anticoagulation with a NOAC over the LMWH–VKA regimen unless the patient has contra-indication(s) to NOACs 1
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Signs and Symptoms of Pulmonary Embolism (PE)
- Acute chest pain
- Shortness of breath
- Syncope
- Tachycardia
- Hypoxemia
Workup and Next Steps in Management and Treatment of PE
- Assessment of the clinical probability of PE using a structured score or clinical gestalt 2
- D-dimer testing if indicated, with a level of less than 500 ng/mL associated with a posttest probability of PE less than 1.85% 2
- Chest imaging, such as computed tomography pulmonary angiography (CTPA), if indicated 2, 3, 4, 5
- Direct oral anticoagulants, such as apixaban, edoxaban, rivaroxaban, or dabigatran, as first-line therapy 2
- Systemic thrombolysis for patients with systolic blood pressure lower than 90 mm Hg 2
Questions to Ask When Taking a History and Physical
- Recent surgery or trauma
- Prior venous thromboembolism event
- Hemoptysis
- Unilateral leg swelling
- Estrogen use
- Heart rate and oxygen saturation level
- Presence of pulmonary pathology, such as acute congestive heart failure, COPD exacerbation, or pneumonia 4
- D-dimer level and results of CTPA, if performed 3, 4, 5
Diagnostic Criteria and Thresholds
- D-dimer level of less than 500 ng/mL associated with a posttest probability of PE less than 1.85% 2
- Higher D-dimer cut-off values (3.87 mg/L, 1.25 mg/L, and 1.34 mg/L) for patients with heart failure, COPD exacerbation, and pneumonia, respectively, to retain 100% sensitivity for PE 4
- Quantitative D-dimer assay with a level of less than 0.4 microg/mL associated with a high negative predictive value for PE 5