Pulmonary embolism: workup and management
Suspected PE. Use pre-test probability (Wells, PERC) to choose D-dimer (age-adjusted) or CTPA. The 2026 AHA/ACC multisociety guideline classifies confirmed PE into clinical categories A–E by symptoms, severity scores, RV strain and hemodynamics, which guide site of care, anticoagulation and advanced therapy.
Working diagnosis
Adult · US guidelines
Draft · awaiting physician review
01Orient
What's new in the evidence
- 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN guideline (first ACC/AHA PE guideline): new PE clinical categories A–E replace low/intermediate/high risk
- Categories A (asymptomatic or incidental) and B (symptomatic, low severity) are suitable for early discharge; categories C–E, with RV strain or hemodynamic compromise, are admitted
- LMWH is preferred over unfractionated heparin when parenteral anticoagulation is needed; DOACs preferred over warfarin
- PE response team (PERT) involvement recommended for higher categories; advanced therapy reasonable in the most severe category and considered in selected intermediate categories
- PEERLESS (2025): large-bore mechanical thrombectomy vs catheter-directed thrombolysis in intermediate-risk PE reduced clinical deterioration and ICU use without a mortality difference
Differential diagnoses
- Pulmonary embolism
- Pneumonia
- ACS
- Pericarditis
- Pneumothorax
- Heart failure
- Musculoskeletal pain
02Assess
Risk scores and decision tools
- Wells score (two-tier) for pre-test probability
- PERC rule when suspicion is low
- Age-adjusted D-dimer (age × 10 ng/mL FEU over 50)
- PESI or sPESI, or Hestia criteria, for early discharge
- RV/LV ratio on CT or echo, troponin and BNP for RV strain
Key history questions
- Sudden dyspnea, pleuritic pain, hemoptysis, syncope
- Recent surgery, immobility, travel
- Active cancer, prior VTE, estrogen therapy, pregnancy
- Leg swelling
- Bleeding risk factors
Examination findings
- Tachycardia, tachypnea, hypoxia, hypotension
- Raised JVP, loud P2 (RV strain)
- Unilateral leg swelling
03Investigate
Initial investigations
- ECG (sinus tachycardia most common; S1Q3T3 is rare)
- Chest X-ray
- Wells score; PERC if low suspicion
- D-dimer (age-adjusted cutoff over 50: age × 10 ng/mL FEU) if Wells low/intermediate
- CBC, BMP, coagulation
Advanced investigations
- CT pulmonary angiography
- V/Q scan if contrast contraindicated
- Troponin, BNP and echo or CT RV/LV ratio for risk stratification
- Lower-limb duplex
04Treat
Immediate management
- High-risk (massive) PE with hypotension: systemic thrombolysis (alteplase 100 mg over 2 h) unless contraindicated
- Start anticoagulation while awaiting imaging if suspicion is high and bleeding risk low
- Oxygen to target; cautious fluids in RV failure
First-line treatment
- DOAC: apixaban 10 mg twice daily for 7 days then 5 mg twice daily, or rivaroxaban 15 mg twice daily for 21 days then 20 mg daily
- LMWH (e.g., enoxaparin 1 mg/kg twice daily) when parenteral anticoagulation is needed; UFH if thrombolysis or a procedure is likely
- Duration at least 3 months; extended (often reduced-dose DOAC) if unprovoked or persistent risk
Second-line treatment
- Catheter-directed therapy or surgical embolectomy if thrombolysis contraindicated or fails
- IVC filter only when anticoagulation is contraindicated
- LMWH or DOAC for cancer-associated VTE per oncology
Specialist referrals
- PE response team or ICU for high or intermediate-high risk
- Hematology for unusual thrombosis or suspected thrombophilia
05Disposition
Admission criteria
- 2026 AHA/ACC category C or higher: RV dysfunction, raised troponin or BNP, or hemodynamic compromise
- Hypoxia, significant pain, high bleeding risk or poor social support
- Hemodynamic instability: ICU and PERT
Safe discharge criteria
- Category A or B: normal vitals, sPESI 0 or Hestia negative, no RV strain
- Anticoagulant supplied and affordable; follow-up within a week
Follow-up timing
- Review at 1-2 weeks, then at 3 months for duration decision
Patient instructions
- Take anticoagulant every day
- Return for worsening breathlessness, chest pain, fainting or bleeding
Monitoring
- Renal function and CBC
- Assess for persistent dyspnea at 3-6 months (CTEPH)
Clinical pearls and pitfalls
- Do not D-dimer patients with high pre-test probability; go straight to imaging
- Check renal function and drug interactions before choosing a DOAC
RefGuidelines and landmark evidence
- GuidelineAHA/ACC multisociety – Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults (2026)PubMed
- TrialPEERLESS: mechanical thrombectomy vs catheter-directed thrombolysis in intermediate-risk PE (2025)PubMed
- GuidelineCHEST – Antithrombotic Therapy for VTE Disease: Second Update (2021)PubMed
- GuidelineASH – Guidelines for Management of VTE: Treatment of DVT and PE (2020)PubMed
- TrialADJUST-PE: age-adjusted D-dimer cutoff (2014)PubMed
- TrialPEITHO: fibrinolysis for intermediate-risk PE (2014)PubMed
- TrialAMPLIFY: apixaban for acute VTE (2013)PubMed
For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.