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Pulmonary Embolism Diagnosis and Management (ESC 2019)

Pulmonary Embolism Diagnosis and Management (ESC 2019): Suspected acute pulmonary embolism → Adults only. Pregnant or postpartum: use a pregnancy PE pat...

Pathway Overview

26 steps

Algorithm Steps

26 total

  1. 01Start

    Suspected acute pulmonary embolism

    Breathlessness, pleuritic chest pain, haemoptysis, syncope, tachycardia or hypoxia with possible PE.

  2. 02Warning

    Adults only. Pregnant or postpartum: use a pregnancy PE pathway

    This pathway is for non-pregnant adults (18 years or older).

    • Pregnancy, postpartum or breastfeeding: pregnancy-adapted diagnosis; treat with LMWH, no DOAC
    • Pregnancy with high-risk PE: thrombolysis or surgical embolectomy may still be considered
    • Children: use a paediatric pathway
  3. 03Decision

    Haemodynamically unstable (suspected high-risk PE)?

    Any one of: cardiac arrest needing CPR; obstructive shock (SBP <90 mmHg, or vasopressor needed for SBP ≥90 mmHg despite adequate filling, with end-organ hypoperfusion); or persistent hypotension (SBP <90 mmHg or a drop of ≥40 mmHg for >15 min, not due to new arrhythmia, hypovolaemia or sepsis).

  4. If Yes
    1. 04Warning

      Unstable: start IV heparin now; RV failure - small fluid bolus only

      Call the senior clinician or PE team. Start IV unfractionated heparin (UFH) now: weight-adjusted bolus, then infusion (local UFH nomogram). Active bleeding or recent intracranial haemorrhage: senior decision before heparin. Past heparin-induced thrombocytopenia (HIT): no heparin; get senior or haematology advice on a non-heparin anticoagulant.

      • Fluid only if CVP is low-normal: 500 mL or less over 15-30 min; more volume worsens RV failure
      • Avoid intubation if possible (risk of collapse): prefer high-flow nasal O2 or NIV; if needed, avoid hypotensive induction drugs
      • Hypotension: noradrenaline first; add dobutamine for low output, never alone while hypotensive. Cardiac arrest: follow ALS
    2. 05Decision

      Unstable: RV dysfunction on echo, PE on CTPA, or arrest from presumed PE?

      Cardiac arrest with presumed PE: yes, go to thrombolysis without waiting for imaging. Otherwise do bedside echo (TTE) first. Do CTPA only if it is available now and the patient is stable enough. Too unstable for CTPA: RV dysfunction on echo (RV/LV >1.0) is enough to treat as high-risk PE.

    3. If Yes
      1. 06Warning

        High-risk PE: check contraindications to thrombolysis

        Absolute contraindication: do not give. Relative: senior or PE team weighs bleeding risk against benefit.

        • Absolute: haemorrhagic stroke or stroke of unknown origin (ever); ischaemic stroke in past 6 months; CNS neoplasm; major trauma, surgery or head injury in past 3 weeks; bleeding diathesis; active bleeding
        • Relative: TIA in past 6 months; oral anticoagulant; pregnancy or first week postpartum; non-compressible puncture; traumatic CPR; SBP >180 mmHg; advanced liver disease; infective endocarditis; active peptic ulcer
        • On an oral anticoagulant: check the last dose time (DOAC) or INR (warfarin)
      2. 07Decision

        Thrombolysis can be given (no contraindication, bleeding risk acceptable)?

      3. If Yes
        1. 08Action

          No contraindication: systemic thrombolysis with alteplase

          Adult. Alteplase (Actilyse) 1 mg/mL after reconstitution. Never give more than 100 mg for PE. Watch for bleeding. Serious bleeding: stop alteplase and heparin.

          • 65 kg or more: alteplase 10 mg IV bolus over 1-2 min, then 90 mg IV infusion over 2 h (total 100 mg)
          • Under 65 kg: alteplase 10 mg IV bolus over 1-2 min, then infusion to a total of 1.5 mg/kg (maximum) over 2 h
          • Cardiac arrest: alteplase 0.6 mg/kg over 15 min (maximum 50 mg) is off-label; continue CPR for 60-90 min after lysis
          • Heparin: ESC allows UFH during alteplase; the AU product information starts or resumes heparin when aPTT is <2x ULN. Follow local protocol
        2. 09Decision

          After thrombolysis: haemodynamically improving?

          No (still unstable or deteriorating): surgical embolectomy or catheter therapy.

        3. If Yes
          1. 10Action

            Anticoagulant: DOAC preferred; not in APS, severe kidney failure, pregnancy

            Active bleeding or other absolute contraindication: no anticoagulant; consider an IVC filter. No DOAC in antiphospholipid syndrome (use warfarin), mechanical heart valve (use warfarin), pregnancy or breastfeeding (use LMWH), liver disease with coagulopathy, or CrCl <15 mL/min (apixaban <25, dabigatran <30 mL/min in AU). No apixaban or rivaroxaban with azole antifungals or HIV protease inhibitors; avoid apixaban with rifampicin, carbamazepine or phenytoin; check other interactions. After high-risk PE: change from UFH to oral only when stable.

            • Apixaban 10 mg twice daily for 7 days, then 5 mg twice daily
            • Rivaroxaban 15 mg twice daily for 21 days, then 20 mg once daily
            • Active cancer: LMWH for the first 6 months; rivaroxaban is an alternative, except in gastrointestinal cancer
            • Dabigatran: only after at least 5 days of parenteral anticoagulation; dose per product information. Warfarin: overlap with LMWH for at least 5 days and until INR 2-3 on 2 consecutive days
          2. 11Outcome

            Anticoagulate at least 3 months; review at 3-6 months

            Stop at 3 months after a first PE with a major transient or reversible risk factor. Unprovoked, persistent risk factor or recurrent VTE: consider indefinite anticoagulation. APS: warfarin indefinitely. Extended treatment, no cancer: after 6 months, apixaban 2.5 mg twice daily or rivaroxaban 10 mg once daily may be considered. Breathlessness or poor exercise tolerance at 3-6 months: echo, and V/Q scan if CTEPH is possible; refer to a PH centre. Review bleeding risk, adherence, and kidney and liver function regularly.

          If No
          1. 12Action

            Lysis contraindicated or failed: surgical embolectomy or catheter therapy

            Where expertise and resources are on site. If not available: discuss urgent transfer with the PE team.

            • Surgical pulmonary embolectomy
            • Percutaneous catheter-directed treatment
            • Refractory collapse or cardiac arrest: VA-ECMO may be considered with embolectomy or catheter therapy
            • Continue IV UFH as the treating team directs
          2. Path rejoins step 10Shared downstream outcome
        If No
        1. Path rejoins step 12Shared downstream outcome
      If No
      1. 13Outcome

        Not in arrest, no RV dysfunction or CTPA negative: find another cause of shock

        High-risk PE is unlikely. Look for other causes of shock or instability. Review the heparin started for suspected PE: stop it if another cause is likely (for example aortic dissection, tamponade or bleeding).

    If No
    1. 14Action

      Stable: assess clinical probability (Wells or revised Geneva)

      Use clinical judgement or a validated rule. Not validated in pregnancy. Wells PE score points:

      • Clinical signs of DVT: 3; PE the most likely diagnosis: 3
      • Heart rate >100/min: 1.5; immobilisation ≥3 days or surgery in past 4 weeks: 1.5
      • Previous DVT or PE: 1.5
      • Haemoptysis: 1; cancer (treated in past 6 months, or palliative): 1
    2. 15Decision

      PE likely (Wells more than 4)?

      Wells 4 or less = PE unlikely. With the 3-level Wells score, high probability (more than 6) = PE likely. Wells 2 or more (intermediate or high probability): start anticoagulation now while tests are done, unless there is active bleeding or high bleeding risk. Past HIT: no heparin.

    3. If Yes
      1. 16Action

        PE likely or D-dimer positive: CTPA (or V/Q scan)

        Wells 2 or more (intermediate or high probability): start anticoagulation now while waiting, if not started, unless there is active bleeding or high bleeding risk. Past HIT: no heparin.

        • Before contrast: check kidney function and past contrast reactions
        • V/Q scan instead if contrast allergy, severe renal impairment, pregnancy, or a young patient with a normal chest X-ray
        • CTPA also shows the RV/LV ratio and other diagnoses
        • Proximal DVT on leg ultrasound also confirms VTE
      2. 17Decision

        PE confirmed on imaging?

        Yes: segmental or more proximal clot on CTPA, high-probability V/Q scan, or proximal DVT on ultrasound. No: normal CTPA or normal perfusion scan. Non-diagnostic V/Q scan: leg ultrasound; exclude PE only if PE unlikely and ultrasound negative, otherwise further imaging. Isolated subsegmental clot: further imaging may be considered.

      3. If Yes
        1. 18Warning

          PE confirmed: check for a contraindication to anticoagulation

          Check before any anticoagulant in the steps below. Past heparin-induced thrombocytopenia (HIT): no UFH or LMWH; use a non-heparin anticoagulant (for example a DOAC).

          • Active major bleeding or recent intracranial haemorrhage: do not anticoagulate; urgent senior advice
          • Absolute contraindication: consider a retrievable IVC filter; start anticoagulation when safe
          • Recent ischaemic stroke, neurosurgery or severe thrombocytopenia: senior decision on timing and agent
        2. 19Action

          Stable, PE confirmed: sPESI, RV function and troponin

          sPESI: 1 point for each item below. Check RV function (echo or CTPA) and troponin, even if sPESI is 0.

          • Age >80 years: 1
          • Cancer: 1
          • Chronic heart failure or chronic lung disease: 1
          • Heart rate ≥110/min: 1; SBP <100 mmHg: 1; SaO2 <90%: 1
        3. 20Decision

          Stable PE: which ESC risk class?

          Intermediate-high: RV dysfunction AND raised troponin, whatever the sPESI (also sPESI 0). Intermediate-low: sPESI 1 or more with one or neither finding, or sPESI 0 with only one finding. Low: sPESI 0 with normal RV and troponin.

        4. Intermediate-high
        5. 21Warning

          Intermediate-high risk: admit to monitored bed; rescue reperfusion ready

          RV dysfunction AND raised troponin, whatever the sPESI (sPESI 0 included).

          • LMWH for the first 2-3 days; UFH if reperfusion may be needed, CrCl ≤30 mL/min or severe obesity
          • No routine primary thrombolysis
          • Deteriorates: rescue thrombolysis, or surgical or catheter therapy
        6. Path rejoins step 10Shared downstream outcome
        7. Intermediate-low
        8. 22Action

          Intermediate-low risk: admit to ward and anticoagulate

          Only one of RV dysfunction or raised troponin (any sPESI), or sPESI 1 or more with neither.

          • LMWH, or a DOAC if eligible (see anticoagulant step)
          • CrCl 30 mL/min or less: UFH, or an adapted LMWH dose (CrCl 15-30 mL/min)
          • No primary thrombolysis
          • Deteriorates: rescue thrombolysis, or surgical or catheter therapy
        9. Path rejoins step 10Shared downstream outcome
        10. Low
        11. 23Action

          Low risk (sPESI 0, normal RV and troponin): consider early discharge

          Home treatment only if no Hestia exclusion criteria, and outpatient care and anticoagulant supply are assured.

          • DOAC if eligible (see anticoagulant step)
          • Arrange early outpatient review
        12. Path rejoins step 10Shared downstream outcome
        If No
        1. 24Outcome

          PE excluded: look for another diagnosis

          Normal D-dimer with PE unlikely, normal CTPA, or normal perfusion scan. No anticoagulation for PE. High probability with normal CTPA: consider further tests if doubt remains.

      If No
      1. 25Action

        PE unlikely: PERC (emergency department only), then high-sensitivity D-dimer

        Emergency department only: low clinical probability, age <50 and all 8 PERC criteria met: PE excluded without D-dimer. Other settings, or any PERC criterion not met: D-dimer.

        • PERC: age <50; HR <100/min; SaO2 >94%; no leg swelling, haemoptysis, recent surgery or trauma, past VTE or oral hormones
        • Use a high-sensitivity D-dimer assay
        • Age over 50: cut-off = age x 10 µg/L (age x 0.01 mg/L); use your lab's units and assay cut-off
        • Do not use D-dimer when PE is likely: a normal result does not exclude PE
      2. 26Decision

        PE unlikely: D-dimer above the cut-off?

        Yes: go to imaging. No (normal D-dimer): PE excluded.

      3. If Yes
        1. Path rejoins step 16Shared downstream outcome
        If No
        1. Path rejoins step 24Shared downstream outcome

Guideline Source

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism

DOI: 10.1093/eurheartj/ehz405View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Not for pregnancy or children: use a pregnancy-adapted or paediatric pathway.
  • Reperfusion (thrombolysis, surgery, catheter therapy) needs a senior or PE team decision and local expertise.
  • Uses ESC 2019 risk classes; the 2026 AHA/ACC guideline uses PE clinical categories A-E.
  • Does not cover isolated subsegmental PE, incidental PE or cancer-associated PE in detail.

Contraindicated Populations

Pregnancy, postpartum or breastfeeding: use a pregnancy-adapted pathwayChildren (under 18 years)

Applicable Regions

EUUSAUGlobal

AU: Alteplase (Actilyse) AU PI for PE: 10 mg bolus then 90 mg over 2 h; under 65 kg total max 1.5 mg/kg; heparin started or resumed when aPTT <2x ULN. Apixaban is contraindicated at CrCl <25 mL/min (AU PI). THANZ 2019: PERC may be used in ANZ EDs; unprovoked or non-surgical provoked PE 3-6 months, then review. Many AU labs report D-dimer in mg/L.

Global: ESC 2019 remains the current ESC/ERS PE guideline. Local protocols vary for thrombolysis, catheter therapy and PE team access.

Version 2Next review: 2027-09-30

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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: Not for pregnancy or children: use a pregnancy-adapted or paediatric pathway.; Reperfusion (thrombolysis, surgery, catheter therapy) needs a senior or PE team decision and local expertise.; Uses ESC 2019 risk classes; the 2026 AHA/ACC guideline uses PE clinical categories A-E.; Does not cover isolated subsegmental PE, incidental PE or cancer-associated PE in detail.. Individual patient factors may require deviation from these recommendations.

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