Pulmonary embolism diagnostic approach
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Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Overview
When a patient presents with the cardinal symptoms of pulmonary embolism (PE), such as sudden onset of dyspnea, pleuritic chest pain, tachypnea, and/or tachycardia, the initial step is to stratify the patient into high risk or non-high risk depending on their hemodynamic status. Patients who are suspected to have PE and who are hemodynamically unstable should be administered anticoagulation and should undergo a CT scan or echocardiography if CT scan is unavailable. Among patients who are hemodynamically stable, the pretest probability of PE should be estimated using one of the available scoring systems, the most used of which is the Wells score. Patients who have a low or intermediate pretest probability of PE should undergo D-dimer testing as the initial test, whereas those who have a high pretest probability of PE should undergo a CT scan without a D-dimer test. Patients at intermediate or high pretest probability of PE should be administered anticoagulation therapy before the completion of the diagnostic testing.
Diagnostic Algorithm
A focused initial rapid evaluation should be performed to identify patients suspected of having PE and in need of immediate intervention.[1][2][3]
Abbreviations: CT: Computed tomography; IV: Intravenous; IVC: Inferior vena cava; PE: Pulmonary embolism; PERC: PE Rule-Out Criteria; RV: Right ventricle; SC: Subcutaneous; VKA: Vitamin K antagonist
Identify cardinal findings that increase the pretest probability of PE:
❑ Dyspnea | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Does the patient who is suspected to have PE have hypotension or shock? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Suspected high-risk PE | Suspected non-high risk PE | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Administer anticoagulation (in case there are no contraindications) during the diagnostic workup | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Is a CT available immediately? | What is the pretest probability of PE? Assess the pretest probability of PE by using one of the risk score: - Wells score - Geneva score - PERC | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Order echocardiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Does the patient have RV overload? | Low pretest probability | Intermediate pretest probability | High pretest probability OR PE is likely | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Administer anticoagulation (in case there are no contraindications) during the diagnostic workup | Administer anticoagulation (in case there are no contraindications) during the diagnostic workup | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | Order CT | Order D-dimer | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Positive | Negative | Positive | Negative | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Is the patient unstable OR no other tests are available? | Is the patient stabilized AND CT is now available? | Order CT | PE is excluded | Order CT | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Positive | Negative | Positive | Negative | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| PE is excluded | Consider thrombolytic therapy or embolectomy | Order CT | PE is confirmed | PE is excluded | PE is confirmed | PE is excluded | PE is confirmed | PE is excluded | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Positive for PE | Negative for PE | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| PE is confirmed | PE is excluded | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2008 Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)
ESC 2008 Guidelines for Suspected High-Risk PE (DO NOT EDIT)[1]
| Class I |
| "1. In high-risk PE, as indicated by the presence of shock or hypotension, emergency CT or bedside echocardiography (depending on availability and clinical circumstances) is recommended for diagnostic purposes. (Level of Evidence: C)" |
ESC 2008 Guidelines for Suspected Non-High-Risk PE (DO NOT EDIT)[1]
| Class I |
| " 1. In non-high-risk PE, basing the diagnostic strategy on clinical probability assessed either implicitly or using a validated prediction rule is recommended. (Level of Evidence: A)" |
| " 2. Plasma D-dimer measurement is recommended in emergency department patients to reduce the need for unnecessary imaging and irradiation, preferably using a highly sensitive assay. (Level of Evidence: A)" |
| " 3. The use of validated criteria for diagnosing PE is recommended. Validated criteria according to clinical probability of PE(low, intermediate or high) are detailed below. (Level of Evidence: B)" |
| Class III |
| "1. Systematic use of echocardiography for diagnosis in haemodynamically stable, normotensive patients is not recommended.(Level of Evidence: C)" |
| Class IIa |
| "1. Pulmonary angiography should be considered when there is discrepancy between clinical evaluation and results of non-invasive imaging tests. (Level of Evidence: C)" |
| Class IIb |
| "1. Lower limb compression venous ultrasonography (CUS) in search of DVT may be considered in selected patients with suspected PE to obviate the need for further imaging tests if the result is positive. (Level of Evidence: B)" |
ESC 2008 Guidelines for Suspected Non-High-Risk PE (DO NOT EDIT)[1]
Low Clinical Probability
| Class I |
| "1. Normal D-dimer level using either a highly or moderately sensitive assay excludes PE. (Level of Evidence: A)" |
| "2. Normal perfusion lung scintigraphy excludes PE. (Level of Evidence: A)" |
| "3. Negative Multi-slice Detector CT (MDCT) safely excludes PE. (Level of Evidence: A)" |
| "4. Negative Single-slice Detector CT (SDCT) only excludes PE when combined with negative proximal compression venous ultrasonography.(Level of Evidence: A)" |
| "5. Compression venous ultrasonography (CUS) showing a proximal DVT confirms PE. (Level of Evidence: B)" |
| "6. SDCT or MDCT showing a segmental or more proximal thrombus confirms PE. (Level of Evidence: A)" |
| Class IIa |
| "1. Non-diagnostic (low or intermediate probability) V/Q scan may exclude PE, (Level of Evidence: B) particularly when combined with negative proximal CUS (Class I,Level of Evidence: A)" |
| "2. If Compression venous ultrasonography shows only a distal DVT, further testing should be considered to confirm PE. (Level of Evidence: B)" |
| "3. Further testing should be considered to confirm PE if SDCT or MDCT shows only subsegmental clots. (Level of Evidence: B)" |
| Class IIb |
| "1. High-probability V/Q scan may confirm PE but further testing may be considered in selected patients to confirm PE. (Level of Evidence: B)" |
Intermediate Clinical Probability
| Class I |
| "1. Normal D-dimer level using a highly sensitive assay excludes PE. (Level of Evidence: A)" |
| "2. Normal perfusion lung scintigraphy excludes PE. (Level of Evidence: A) " |
| "3. In case of a non-diagnostic V/Q scan, further testing is recommended to exclude or confirm PE. (Level of Evidence: B)" |
| "4. Negative MDCT excludes PE. (Level of Evidence: A)" |
| "5. Negative SDCT only excludes PE when combined with negative proximal CUS.(Level of Evidence: A)" |
| "6. High-probability ventilation–perfusion lung scintigraphy confirms PE. (Level of Evidence: A)" |
| "7. Compression venous ultrasonography showing a proximal DVT confirms PE. (Level of Evidence: B)" |
| "8. SDCT or MDCT showing a segmental or more proximal thrombus confirms PE. (Level of Evidence: A)" |
| Class IIa |
| "1. Further testing should be considered if D-dimer level is normal when using a less sensitive assay. (Level of Evidence: B) " |
| "2. If compression venous ultrasonography shows only a distal DVT, further testing should be considered. (Level of Evidence: B)" |
| Class IIb |
| "1. Further testing may be considered in case of subsegmental clots to confirm PE. (Level of Evidence: B)" |
High Clinical Probability
| Class I |
| "1. High-probability ventilation–perfusion lung scintigraphy confirms PE. (Level of Evidence: A) " |
| "2. Compression venous ultrasonography showing a proximal DVT confirms PE. (Level of Evidence: B)" |
| "3. SDCT or MDCT showing a segmental or more proximal thrombus confirms PE.(Level of Evidence: A)" |
| Class III |
| "1. D-dimer measurement is not recommended in high clinical probability patients as a normal result does not safely exclude PE even when using a highly sensitive assay. (Level of Evidence: C)" |
| Class IIa |
|
"1. In patients with a negative CT, further tests should be considered in selected patients to exclude PE. (Level of Evidence: B) " |
| Class IIb |
| "1. If compression venous ultrasonography shows only a distal DVT, further testing should be considered. (Level of Evidence: B)" |
| "2. Further testing may be considered where there are subsegmental clots, to confirm PE. (Level of Evidence: B)" |
References
- ↑ 1.0 1.1 1.2 1.3 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
- ↑ Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.
- ↑ Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ; et al. (2012). "Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e419S–94S. doi:10.1378/chest.11-2301. PMC 3278049. PMID 22315268.