Diagnosis
Management
Prescribing information
Background information
Pulmonary embolism: Summary
- Pulmonary embolism (PE) is a life-threatening condition in which one or more emboli, usually arising from a blood clot formed in the veins, are lodged in and obstruct the pulmonary arterial system, causing severe respiratory dysfunction.
- The most common source of pulmonary emboli is deep vein thrombosis (DVT) in the lower limbs.
- Major risk factors for PEinclude:
- DVT.
- Recent surgery.
- Significant immobility.
- Previous DVT or PE.
- Active cancer.
- Antiphospholipid antibody syndrome.
- Lower limb trauma.
- Recent myocardial infarction.
- Increasing age.
- Family history of DVT.
- Pregnancy and, in particular, for 6 weeks postpartum.
- Other risk factors include the use of combined oral contraception or hormone replacement therapy, cigarette smoking, long-duration travel, obesity, and comorbidities.
- Left untreated, the prognosis is poor and the risk of death is high. Following treatment, some people develop complications, such as chronic thromboembolic pulmonary hypertension.
- PE should be suspected in people with one or more of the following (especially if there arerisk factorsforPE):
- Dyspnoea, haemoptysis, chest pain, syncope or pre-syncope, tachypnoea, features of DVT.
- If PE is suspected, a history, physical examination, and investigations should be carried out to exclude other causesof symptoms, such as acute coronary syndromeand pneumonia.
- Immediate admission to hospital should be arranged if the person:
- Has signs of haemodynamic instability.
- Is pregnantor hasgiven birth within the past 6 weeks.
- For all other people, the two-level PE Wells score should be used to estimate the clinical probability of PE.
- For people with a Wells score of more than 4 points (PE likely):
- Hospital admission for an immediate computed tomography pulmonary angiogram (CTPA) should be arranged.
- If CTPA cannot be carried out immediately, interim therapeutic anticoagulation should be offered, then hospital admission arranged.
- For people with a Wells score of 4 points or less (PE unlikely), a D-dimer test should be arranged with results available within 4 hours.
- If the test result cannot be obtained within 4 hours, interim therapeutic anticoagulation should be offered while awaiting the result.
- If the test is positive, hospital admission for an immediate CTPA should be arranged. If CTPA cannot be carried out immediately, interim therapeutic anticoagulation should be offered, then hospital admission arranged.
- If the test is negative, interim therapeutic anticoagulation should be stopped and an alternative diagnosis considered.
- If PE is confirmed, and anticoagulation treatment is started, in secondary care, follow-up of the person in primary care should include:
- Adequate monitoring of treatment.
- Ensuring that the person is provided with an anticoagulant information booklet, an anticoagulant alert card, and verbal and written information on anticoagulation treatment.
- Ensuring people with unprovoked PE are offered investigations to assess the possibility of undiagnosed cancer and, where appropriate, hereditary thrombophilia testing.
