Pulmonary Embolism Diagnosis and Management

Clinical Presentation

Fever is present in approximately 7% of pulmonary embolism (PE) cases, according to the American College of Physicians, in patients with PE 1
Pleuritic chest pain occurs in 52% of PE cases, typically caused by pleural irritation from distal emboli, as reported by the American Thoracic Society 1, 2
Dyspnea is the most common symptom, present in approximately 80% of PE patients, according to the American College of Chest Physicians 1
CT showing segmental pulmonary artery defect is diagnostic of pulmonary embolism, as stated by the American College of Radiology 1
The British Thoracic Society guidelines emphasize that the combination of tachypnea, pleuritic pain, and arterial hypoxemia strongly suggests PE, and the absence of all three virtually excludes the diagnosis, with a strength of evidence rated as high 3, 4, 5, 6

Predisposing factors are found in 80-90% of PE patients, with medical illness and medications being common contributors, according to the British Thoracic Society, with a moderate strength of evidence 3, 4, 5
Assessing clinical probability using risk factors, such as corticosteroid use, is crucial in diagnosing PE, as recommended by the American College of Physicians, with a high strength of evidence 3, 7
Obtaining D-dimer levels can help exclude PE in appropriate clinical contexts, as stated by the American College of Emergency Physicians, with a moderate strength of evidence 3, 4, 5
Lower extremity venous ultrasound is recommended as a first-line investigation in patients with suspected PE, especially with prior risk factors, according to the American Institute of Ultrasound in Medicine, with a high strength of evidence 3, 7
CT pulmonary angiography confirms the diagnosis and characterizes embolic burden, as reported by the American College of Radiology, with a high strength of evidence 1

Anticoagulation should be initiated immediately based on high clinical suspicion before diagnostic confirmation is complete, as recommended by the British Thoracic Society, with a high strength of evidence 3, 4, 7
The British Thoracic Society recommends starting heparin on the basis of high or intermediate clinical suspicion before the diagnosis is clarified, with a moderate strength of evidence 3, 4