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Pulmonary embolism

Key sources
The following summarized guidelines for the evaluation and management of pulmonary embolism are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024; 2017), the American Society of Hematology (ASH 2023; 2020), the American Heart Association (AHA 2020), the Society for Vascular Medicine (SVM/AHA/ACC/ACS/ACCP/SIR 2020), the European Society of Cardiology (ESC 2019), and the American College of Chest Physicians (ACCP 2016).


1.Screening and diagnosis

Diagnostic criteria: use validated diagnostic criteria in patients with suspected PE without hemodynamic instability.
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2.Classification and risk stratification

Risk stratification: stratify patients with suspected or confirmed PE, based on the presence of hemodynamic instability, to identify patients at high risk of early mortality.
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3.Diagnostic investigations

History and physical examination
Elicit a thorough history and perform a physical examination to diagnose or exclude life-threatening causes of pleuritic chest pain.
Suspect PE in all patients with pleuritic chest pain, as it is the most common life-threatening cause of this symptom. Use a validated clinical decision rule to guide the use of additional tests, including D-dimer and imaging.

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  • D-dimer

  • Diagnostic imaging

4.Medical management

Setting of care: consider offering home treatment over hospital treatment for patients with PE with a low risk for complications.

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  • Indications for anticoagulation

  • Choice of anticoagulation

  • Duration of anticoagulation (unprovoked PE)

  • Duration of anticoagulation (provoked PE)

  • Duration of anticoagulation (cancer-associated thrombosis)

  • Aspirin therapy post anticoagulation

  • Thrombolytic therapy

5.Therapeutic procedures

Indications for inferior vena cava filter placement: as per ASH 2020 guidelines, consider offering anticoagulation alone over anticoagulation plus insertion of an IVC filter in patients with PE and hemodynamic compromise.

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  • Anticoagulation with inserted IVC filter

  • Systemic thrombolytic therapy

  • Catheter-assisted thrombectomy

6.Surgical interventions

Surgical thromboendarterectomy: as per ESC 2019 guidelines, perform surgical pulmonary embolectomy in patients with high-risk PE if thrombolysis is contraindicated or has failed.

7.Specific circumstances

Pregnant patients, antepartum thromboprophylaxis
Consider obtaining testing for the known familial thrombophilia in females with a family history of VTE and known homozygous factor V Leiden, a combination of factor V Leiden and prothrombin G20210A, or antithrombin deficiency in the family. Consider administering antepartum thromboprophylaxis in patients with the same familial thrombophilia.
Consider either obtaining testing for the known familial thrombophilia or omitting testing for thrombophilia to guide antepartum prophylaxis in females with a family history of VTE and known protein C or protein S deficiency in the family.

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  • Pregnant patients (postpartum thromboprophylaxis)

  • Pregnant patients (evaluation)

  • Pregnant patients (management of PE)

  • Patients with antiphospholipid syndrome

  • Patients with cardiac arrest

8.Preventative measures

Thrombophilia testing for minor provoking factors: avoid obtaining testing for factor V Leiden or prothrombin G20210A (low-risk thrombophilia) to guide thromboprophylaxis in patients with a family history of factor V Leiden (with or without VTE) and having a minor provoking risk factor for VTE, such as immobility or minor injury, illness, or infection.
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  • Thrombophilia testing before hormone therapy (combined oral contraceptives)

  • Thrombophilia testing before hormone therapy (hormone replacement therapy)

  • Thromboprophylaxis in hospitalized patients

  • Anticoagulation for secondary prevention

9.Follow-up and surveillance

Indications for specialist referral: refer symptomatic patients with mismatched perfusion defects on V/Q lung scan beyond 3 months after acute PE to a pulmonary hypertension/chronic thromboembolic pulmonary hypertension expert center, taking into account the results of echocardiography, natriuretic peptide, and/or cardiopulmonary exercise testing.

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  • Follow-up

  • Transition of care

  • Management of recurrent PE