Pulmonary Embolism Management

Diagnosis and Risk Stratification

The American College of Cardiology recommends risk stratification based on hemodynamic stability as the critical first step in managing pulmonary embolism (PE) 1, 2, 3
High-risk PE is characterized by cardiogenic shock and/or persistent arterial hypotension, requiring immediate systemic thrombolysis 2, 3
Intermediate-risk PE is defined as hemodynamically stable with evidence of right ventricular dysfunction on imaging or biomarkers 2
Low-risk PE is characterized by hemodynamically stable patients without right ventricular dysfunction 2
Clinical probability assessment using validated criteria (Wells score or Geneva score) should be performed before ordering tests 3
D-dimer measurement is only recommended in patients with low or intermediate clinical probability 3, 4
A normal D-dimer result excludes PE and no further testing is needed 4, 3

CT pulmonary angiography (CTPA) is the initial lung imaging modality of choice for non-massive PE 3
If CTPA is negative but clinical suspicion remains high, lower limb compression ultrasonography should be performed 4
In pregnancy, CTPA delivers lower fetal radiation than perfusion scanning in the first/second trimester and can be performed safely 4

Systemic thrombolytic therapy is the first-line treatment for high-risk PE unless contraindicated 1, 3
Immediate actions for high-risk PE include starting intravenous unfractionated heparin, administering oxygen, and correcting systemic hypotension 1, 2, 3
For intermediate-risk PE, anticoagulation should be initiated without delay, and thrombolysis should only be considered in selected patients with clinical deterioration 1, 2, 3
Low-risk PE patients should be initiated on low-molecular-weight heparin (LMWH) or fondaparinux 2, 3

Non-vitamin K antagonist oral anticoagulants (NOACs) are preferred over vitamin K antagonists for most patients 2, 3
The preferred NOACs are apixaban, dabigatran, edoxaban, or rivaroxaban 2, 3
NOACs should not be used in patients with severe renal impairment or antiphospholipid antibody syndrome 3
The duration of anticoagulation should be at least 3 months, with consideration for extended anticoagulation in certain patient populations 2, 3

In pregnancy, normal D-dimer has the same exclusion value as non-pregnant patients, and CTPA is safe with fetal radiation <50 mSv 4
IVC filters should not be routinely used in patients with PE, but may be considered in patients with absolute contraindications to anticoagulation and high VTE recurrence risk 4, 3

Patients should be routinely re-evaluated 3-6 months after acute PE 1, 2, 3
An integrated care model should be implemented for optimal hospital-to-ambulatory transition 1, 2, 3
Patients with persistent symptoms or mismatched perfusion defects beyond 3 months should be referred to a pulmonary hypertension expert center 1