In a 79‑year‑old man with a resolved deep‑vein thrombosis, a pulmonary embolism one year ago, and currently on apixaban (Eliquis), is routine screening for pulmonary embolism recommended?

Routine Screening for Pulmonary Embolism is NOT Recommended

Routine screening for pulmonary embolism is not indicated in asymptomatic patients, even with a history of prior PE and DVT, as long as they remain on appropriate anticoagulation. 1

Why Screening is Not Recommended

The diagnostic approach to pulmonary embolism is symptom-driven, not screening-based. The entire diagnostic algorithm begins with clinical suspicion based on symptoms such as:

• Breathlessness and/or tachypnea >20/min 1
• Pleuritic chest pain 1
• Hemoptysis 1
• Unexplained hypoxia 1

Without these symptoms, no diagnostic testing should be performed. 1

The Diagnostic Algorithm Only Applies to Symptomatic Patients

The European Society of Cardiology and British Thoracic Society guidelines make clear that D-dimer testing and imaging are not routine screening tests for PE. 1 These tests should only be considered when there is reasonable clinical suspicion based on symptoms. 1

Key points about D-dimer testing:

• D-dimer is not a routine "screening" test for PE 1
• It should only be considered where there is reasonable suspicion of PE 1
• It should not be performed where an alternative diagnosis is highly likely 1

Current Management for This Patient

For a 79-year-old man with resolved DVT and PE one year ago who is currently on apixaban:

The appropriate management is:

• Continue therapeutic anticoagulation as prescribed 1
• Routine re-evaluation at 3-6 months after acute PE to assess for symptoms and post-PE sequelae 1
• Regular assessment of drug tolerance, adherence, hepatic and renal function, and bleeding risk 1
• No routine imaging or D-dimer testing in the absence of symptoms 1

When to Pursue Diagnostic Testing

Testing should only be initiated if the patient develops new symptoms suggestive of recurrent PE:

• New or worsening dyspnea 1
• Chest pain 1
• Hemoptysis 1
• Tachypnea or tachycardia 1
• Hypoxia 1

If symptoms develop, then proceed with clinical probability assessment using Wells score or Geneva score, followed by appropriate D-dimer testing (age-adjusted: 79 × 10 = 790 ng/mL cutoff) or imaging as indicated. 1, 2

Critical Pitfall to Avoid

Do not order "surveillance" imaging or D-dimer tests in asymptomatic patients on anticoagulation. This leads to false-positive results, unnecessary anxiety, additional testing, and potential harm without improving outcomes. 1, 2 D-dimer levels can remain elevated for months after VTE and in elderly patients due to age alone, making them non-diagnostic in this screening context. 2