Suspected Pulmonary Embolism
Clinical suspicion of PE: dyspnea, chest pain, hemoptysis, tachycardia, hypoxia
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Pulmonary MedicineEmergency
Pulmonary Embolism Diagnosis and Management (ESC 2019)
Pulmonary Embolism Diagnosis and Management (ESC 2019): Suspected Pulmonary Embolism → Hemodynamically Unstable? → ⚠️ HIGH-RISK PE → Thrombolysis Candid...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Decision Hemodynamically Unstable?
Shock or persistent hypotension
- SBP <90 mmHg for >15 min
- SBP drop ≥40 mmHg for >15 min
- Need for vasopressors
- Signs of end-organ hypoperfusion
03Warning ⚠️ HIGH-RISK PE
Immediate action required
- Resuscitate: IV access, O2, vasopressors
- Bedside echo if available (RV dysfunction)
- Emergent CTPA if stable enough
- Consider bedside echo to guide therapy
04Decision Thrombolysis Candidate?
Assess for reperfusion therapy
- Alteplase 100mg over 2h (or 0.6mg/kg over 15min if arrest)
- Contraindications: Recent surgery, stroke, active bleeding
- If contraindicated: Surgical/catheter embolectomy
05Action Systemic Thrombolysis
Alteplase 100mg IV over 2 hours
- Alteplase: 10mg IV bolus, then 90mg over 2h
- Hold heparin during infusion
- Monitor for bleeding complications
- Restart anticoagulation after
06Outcome Anticoagulation Therapy
Duration based on risk factors
- Provoked PE: 3 months minimum
- Unprovoked PE: Extended/indefinite
- Cancer: LMWH or DOAC long-term
- Reassess bleeding risk annually
07Action Surgical/Catheter Embolectomy
When thrombolysis contraindicated
- Surgical embolectomy if available
- Catheter-directed therapy
- ECMO as bridge if needed
- Path rejoins step 06Shared downstream outcome
08Action Assess Pre-test Probability
Wells Score or Geneva Score
- Wells PE Score:
- • Clinical DVT signs: +3
- • PE most likely diagnosis: +3
- • HR >100: +1.5
- • Immobilization/surgery: +1.5
- • Previous VTE: +1.5
- • Hemoptysis: +1
- • Malignancy: +1
09Decision PE Probability?
Based on clinical assessment
- PE Unlikely: Wells ≤4
- PE Likely: Wells >4
- Or use 3-level: Low/Intermediate/High
10Action D-dimer Testing
For PE unlikely patients
- High-sensitivity assay
- Age-adjusted cutoff: Age × 10 μg/L (if >50)
- Negative D-dimer rules out PE if unlikely
11Outcome PE Excluded
Consider alternative diagnoses
12Action CT Pulmonary Angiography
Gold standard imaging
- First-line imaging for PE diagnosis
- Can assess RV size (RV/LV ratio)
- Also evaluates for alternative diagnoses
13Decision PE Confirmed?
CTPA or V/Q positive
14Action Risk Stratification (sPESI)
Simplified PE Severity Index
- Age >80: +1
- Cancer: +1
- Chronic cardiopulmonary disease: +1
- HR ≥110: +1
- SBP <100: +1
- SpO2 <90%: +1
- Score 0 = Low risk
15Action Intermediate-High Risk
sPESI ≥1 + RV dysfunction + elevated troponin
- Admit to monitored bed
- Anticoagulation: LMWH or UFH
- Close monitoring for deterioration
- Consider rescue thrombolysis if decompensates
- Path rejoins step 06Shared downstream outcome
16Action Intermediate-Low Risk
sPESI ≥1 but no RV dysfunction OR no biomarker elevation
- Hospital admission
- Anticoagulation: DOAC preferred
- Standard monitoring
- Path rejoins step 06Shared downstream outcome
17Action Low Risk (sPESI = 0)
Consider early discharge/home treatment
- Home treatment if: Stable, no contraindications
- DOAC preferred (Rivaroxaban, Apixaban)
- Follow-up in 1 week
- Path rejoins step 06Shared downstream outcome
- Path rejoins step 11Shared downstream outcome
- Path rejoins step 12Shared downstream outcome
Guideline Source
2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address PE in pregnancy (special considerations apply)
- Cancer-associated PE may require different anticoagulation
- Thrombolysis dosing requires individual assessment
- Does not cover subsegmental PE management controversy
Contraindicated Populations
pregnancy_requires_modification
Applicable Regions
EUUSGlobal
Global: ESC guidelines widely adopted; local protocols may vary for thrombolysis access
Version 1Next review: 2027-01-01
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Pulmonary Embolism Severity Index (PESI)
30-day mortality risk stratification for acute pulmonary embolism
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Frequently Asked Questions
What is the Pulmonary Embolism Diagnosis and Management (ESC 2019)?
The Pulmonary Embolism Diagnosis and Management (ESC 2019) is a emergency clinical algorithm for Pulmonary Medicine. It provides a structured decision tree to guide clinical decision-making, based on 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism.
What guideline is the Pulmonary Embolism Diagnosis and Management (ESC 2019) based on?
This algorithm is based on 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism (DOI: 10.1093/eurheartj/ehz405).
What are the limitations of the Pulmonary Embolism Diagnosis and Management (ESC 2019)?
Known limitations include: Does not address PE in pregnancy (special considerations apply); Cancer-associated PE may require different anticoagulation; Thrombolysis dosing requires individual assessment; Does not cover subsegmental PE management controversy. Individual patient factors may require deviation from these recommendations.
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