How do I manage a patient with suspected acute pulmonary embolism?

Abstract

Acute PE is a cardiovascular emergency and early risk stratification is important in the management of these patients. Pre-test clinical prediction models together with D-dimer assays help select those who require imaging. Each hospital should develop a strategy for investigating patients with suspected PE depending on local expertise, resources and the patient population.

Fig 1.

A survey of the conference delegates showed that most clinicians had access to both V/Q scintigraphy and computed tomography (CT) pulmonary angiography (CTPA). Here is a possible diagnostic algorithm for haemodynamically stable patients with a suspected pulmonary embolism (PE). Patients with an intermediate pre-test probability could follow the path of the low probability patients if a highly sensitive D-dimer test is used and local assessment shows this to be safe. Each hospital should develop a diagnostic strategy which will depend on local resources, expertise and the patient population. CXR=chest X-ray. Adapted with permission from BMJ Publishing Group Ltd.

Fig 2.

Computed tomography (CT) pulmonary angiography (CTPA) showing a saddle embolus extending into the right and left pulmonary arteries (white arrows). The secondary effects of PE are also shown including dilatation of the main pulmonary artery (PA) compared to the aorta (A), a dilated right atrium (RA) and right ventricle (RV), and evidence of tricuspid regurgitation.