Pulmonary Embolism Diagnosis and Management (ESC 2019)

Algorithm Steps

1. ▶

   Start

   Suspected Pulmonary Embolism

   Clinical suspicion of PE: dyspnea, chest pain, hemoptysis, tachycardia, hypoxia

   1. ◆

      Decision

      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
      1. ⚠

         Warning

         ⚠️ 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
         1. ◆

            Decision

            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
            1. ●

               Action

               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
               1. ✓

                  Outcome

                  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
            2. ●

               Action

               Surgical/Catheter Embolectomy

               When thrombolysis contraindicated

               • Surgical embolectomy if available
               • Catheter-directed therapy
               • ECMO as bridge if needed
      2. ●

         Action

         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
         1. ◆

            Decision

            PE Probability?

            Based on clinical assessment

            • PE Unlikely: Wells ≤4
            • PE Likely: Wells >4
            • Or use 3-level: Low/Intermediate/High
            1. ●

               Action

               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
               1. ✓

                  Outcome

                  PE Excluded

                  Consider alternative diagnoses

               2. ●

                  Action

                  CT Pulmonary Angiography

                  Gold standard imaging

                  • First-line imaging for PE diagnosis
                  • Can assess RV size (RV/LV ratio)
                  • Also evaluates for alternative diagnoses
                  1. ◆

                     Decision

                     PE Confirmed?

                     CTPA or V/Q positive

                     1. ●

                        Action

                        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
                        1. ●

                           Action

                           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
                        2. ●

                           Action

                           Intermediate-Low Risk

                           sPESI ≥1 but no RV dysfunction OR no biomarker elevation

                           • Hospital admission
                           • Anticoagulation: DOAC preferred
                           • Standard monitoring
                        3. ●

                           Action

                           Low Risk (sPESI = 0)

                           Consider early discharge/home treatment

                           • Home treatment if: Stable, no contraindications
                           • DOAC preferred (Rivaroxaban, Apixaban)
                           • Follow-up in 1 week