Management of Burning Chest Pain in a Patient with History of Pulmonary Embolism

Initial Assessment

The British Thoracic Society recommends assessing clinical probability of PE by evaluating risk factors and clinical presentation 1
The British Thoracic Society suggests considering whether another diagnosis is unlikely and whether major risk factors are present, such as recent immobility, surgery, trauma, pregnancy, medical illness, or previous VTE 1
The British Thoracic Society advises recording respiratory rate, as most patients with PE are breathless and/or tachypneic (>20/min) 1
The British Thoracic Society recommends obtaining chest radiography, ECG, and arterial gas measurements for all patients with suspected PE 1
In the absence of tachypnea (>20/min), pleuritic pain, and arterial hypoxemia, a diagnosis of PE can be excluded, according to the British Thoracic Society 1

The British Thoracic Society classifies clinical probability as low, intermediate, or high, based on the presence of risk factors and alternative diagnoses 1
The American College of Physicians recommends D-dimer testing if clinical probability is low or intermediate 2
The American College of Physicians advises using age-adjusted D-dimer thresholds (age × 10 ng/mL) for patients older than 50 years 3
A negative D-dimer result with validated tests can exclude PE in appropriate clinical scenarios, according to the British Thoracic Society 1

The British Thoracic Society recommends leg vein imaging as a first-line investigation for patients with history of PE presenting with chest pain 1
The American College of Physicians suggests considering lower-extremity venous ultrasonography before CT, especially in patients with lower-extremity symptoms 3
The British Thoracic Society recommends CTPA (CT pulmonary angiography) in patients with abnormal chest radiograph or chronic cardiorespiratory disease 1
The American College of Physicians advises considering V/Q scanning for patients with multiple previous CTs to reduce radiation exposure 3
The British Thoracic Society recommends initiating anticoagulation promptly if PE is confirmed or highly suspected 1
Consider outpatient treatment if the patient is not unduly breathless, has no medical or social contraindications, and there is an efficient protocol in place, according to the British Thoracic Society 1

The American College of Physicians recommends considering alternative diagnostic approaches to reduce radiation exposure for patients with history of multiple CTs for PE 3
The British Thoracic Society advises avoiding overdiagnosis or underdiagnosis of PE, as both are common in clinical practice 1
The British Thoracic Society recommends not relying solely on clinical features for patients with indeterminate lung scans; further imaging is required 1
The British Thoracic Society suggests not automatically assuming recurrent PE in a patient with history of PE presenting with chest pain; consider alternative diagnoses 1