Pulmonary embolism: update on diagnosis and management

Abstract

Summary Pulmonary embolism (PE) is a potentially life‐threatening condition, mandating urgent diagnosis and treatment. The symptoms of PE may be non‐specific; diagnosis therefore relies on a clinical assessment and objective diagnostic testing. A clinical decision rule can determine the pre‐test probability of PE. If PE is “unlikely”, refer for a D‐dimer test. If the D‐dimer result is normal, PE can be excluded. If D‐dimer levels are increased, refer for chest imaging. If PE is “likely”, refer for chest imaging. Imaging with computed tomography pulmonary angiogram is accurate and preferred for diagnosing PE, but may detect asymptomatic PE of uncertain clinical significance. Imaging with ventilation–perfusion (VQ) scan is associated with lower radiation exposure than computed tomography pulmonary angiogram, and may be preferred in younger patients and pregnancy. A low probability or high probability VQ scan is helpful for ruling out or confirming PE, respectively; however, an intermediate probability VQ scan requires further investigation. The direct oral anticoagulants have expanded the anticoagulation options for PE. These are the preferred anticoagulant for most patients with PE because they are associated with a lower risk of bleeding, and have the practical advantages of fixed dosage, no need for routine monitoring, and fewer drug interactions compared with vitamin K antagonists. Initial parenteral treatment is required before dabigatran and edoxaban.

Psoas Muscle Area Measured with Computed Tomography at Admission to Intensive Care Unit: Prediction of In-Hospital Mortality in Patients with Pulmonary Embolism

“…The clinical manifestations of PE range from no symptoms to sudden death, depending on the degree of obstruction of the pulmonary vasculature and the cardiovascular reserve of the patient. Hospitalization is considered in patients with a high PESI score, additionally with either hemodynamic instability, need for oxygen or parenteral analgesics, or comorbidities [13,14].…”

Current Management of Acute Pulmonary Embolism

“…5) While low molecular weight heparin bridged to warfarin was once the treatment of choice, direct oral anticoagulants (DOACs) are now recommended as the first-line therapy for most patients. 7,32) DOACs including dabigatran, apixaban, rivaroxaban, and edoxaban have been shown to be non-inferior to warfarin in a series of large meta-analyses including the RE-COVER, RE-COVER II, EINSTEIN-DVT, EIN-STEIN-PE, AMPLIFY, and Hokusai-VTE trials. 33) In addition, DOACs have many potential advantages over warfarin, including rapid onset, decreased risk of bleeding, fewer food and pharmaceutical interactions, and fewer monitoring requirements.…”

“…33) In addition, DOACs have many potential advantages over warfarin, including rapid onset, decreased risk of bleeding, fewer food and pharmaceutical interactions, and fewer monitoring requirements. [32][33][34]…”

Modern diagnostics in emergency medicine

“…From correct sampling to transport, preparation and/or manual analysis, to the final interpretation of findings, it requires a complementary interdisciplinary interplay, especially under time pressure. Careful interpretation of laboratory results by emergency physicians is crucial [4,77,78] for correct diagnosis (e.g. elevated cardiac markers in non-ST-segment-elevation acute coronary syndrome) or for the exclusion of possible causes of acute illness (e.g.…”