Pulmonary Embolism Diagnosis and Management

Definition and Pathophysiology

Pulmonary embolism (PE) occurs when a blood clot travels through the venous system and occludes a pulmonary artery, typically originating from deep vein thrombosis (DVT) in the lower limbs, as stated by the European Respiratory Journal 1

Symptoms and signs of PE are highly non-specific and may include chest pain, dyspnoea, syncope, haemoptysis, cardiac arrest, or a combination of these, according to the European Heart Journal 2, 3
The most frequent ECG signs are limited to sinus tachycardia or atrial fibrillation, as reported by the European Heart Journal 3
In more severe cases, ECG may show signs of right ventricular overload, including inversion of T waves in leads V1–V4, QR pattern in V1, S1Q3 pattern, and incomplete or complete right bundle-branch block, as stated by the European Heart Journal 3

Initial risk stratification is essential and should be based on hemodynamic status to distinguish between high-risk and non-high-risk PE, as recommended by the European Heart Journal 4
PE is classified into three categories: high-risk (massive), intermediate-risk (submassive), and low-risk, based on hemodynamic stability and evidence of right ventricular dysfunction, as stated by the European Heart Journal 4, 5

The use of clinical prediction scores to determine the likelihood of PE is highly recommended by the European Heart Journal 3
Definitive diagnosis requires pulmonary perfusion imaging, typically CT pulmonary angiography, as stated by the European Heart Journal 3
Compression ultrasonography (CUS) can detect DVT in 30-50% of patients with PE, and finding a proximal DVT is sufficient to warrant anticoagulant treatment, according to the European Respiratory Journal 1

Immediate systemic thrombolytic therapy is recommended for patients with cardiogenic shock and/or persistent hypotension, as stated by the European Heart Journal 5
Anticoagulation is the primary treatment for intermediate-risk and low-risk PE, and should be initiated immediately while completing diagnostic workup, unless absolutely contraindicated, as recommended by the European Heart Journal 5
Direct oral anticoagulants (DOACs) like apixaban, rivaroxaban, edoxaban, or dabigatran are preferred over vitamin K antagonists for hemodynamically stable patients, as stated by the European Heart Journal 5

In patients with cancer, edoxaban or rivaroxaban should be considered as alternatives to low molecular weight heparin, except in those with gastrointestinal cancer, as recommended by the European Heart Journal 5
For patients with antiphospholipid syndrome, indefinite treatment with vitamin K antagonists is recommended, as stated by the European Heart Journal 5

Continuous monitoring of vital signs, oxygen saturation, and hemodynamic parameters is essential in the CVICU, as stated by the European Heart Journal 3
Serial echocardiographic assessments may be valuable to monitor RV function and response to treatment, as recommended by the European Heart Journal 6
Extended anticoagulation should be considered for patients without identifiable risk factors for the initial PE event, as stated by the European Heart Journal 5