Pulmonary Embolism

Pulmonary embolism is a blockage of one of the pulmonary arteries that supply blood to the lungs
mostly caused by the clots that travel to the lungs from deep veins in the legs. Therefore, it can be
life threatening. However, early diagnosis and prompt treatment greatly reduces the risk of death.

Clinical Features
Pulmonary embolism symptoms can vary greatly depending on the size and location of the clots.

Signs and Symptoms

Common signs and symptoms include:

• Tachypnoea
• Tachycardia
• Crackles
• Fever

Other signs and symptoms that can occur with pulmonary embolism include:

• Pleuritic chest pain

• Dyspnoea
• Cough and haemoptysis
• Hypoxia
• Elevated JVP
• Pleural rub
• Systemic hypotension and cardiogenic shock (in case of large embolism)
• Gallop rhythm

Investigations
Chest X-ray is the best initial investigation to rule out other causes of dyspnoea like pneumonia
and pneumothorax. After excluding other causes of dyspnea perform 2-level PE Wells score.
2-Level PE Wells Score
Clinical Features Points
DVT signs and symptoms present 3
An alternative diagnosis is less likely 3
HR> 100 beats per minute 1.5
Surgery in last 4 weeks or 1.5
immobilization for more than 3 days
Previous PE/DVT 1.5
Hemoptysis 1
Malignancy (treated in the last 6 1
months or on treatment)

Interpretation
• PE likely - >4 points
• PE unlikely - <4 points

If PE is Likely >4 Points

Arrange an immediate computed tomography pulmonary angiogram (CTPA) and start direct oral
anticoagulant (DOAC) such as apixaban or rivaroxaban.

• If CTPA positive: Continue DOAC.

• If CTPA negative: Arrange a proximal leg vein ultrasound scan if DVT is suspected.

If PE is Unlikely <4 Points

Arrange a D-dimer test.

• If D-dimer positive: arrange CTPA.

• If D-dimer negative: then PE unlikely, consider an alternative diagnosis.

N.B. CTPA is gold standard investigation for pulmonary embolism.

Other Investigations
1. ECG: Typical ECG changes are large S wave in lead I, a large Q wave in lead III and an
inverted T wave in lead III (S1Q3T3).
2. V/Q scan: Investigation of choice if there is renal impairment.
• If patient is pregnant and has signs and symptoms of PE and DVT as well then
compression ultrasonography should be performed, if it confirms the presence of
DVT then further investigations are not necessary.
• In pregnancy, V/Q scan is slightly preferred over CTPA, as CTPA increases the
risk of maternal breast cancer.

Management
The cornerstone of PE management is anticoagulant therapy. This was previously done with
warfarin, preceded by heparin until the INR was stable. However, now due to development of
direct oral anticoagulants (DOAC) modern management has been changed.

If Patient is Hemodynamically Stable

Apixaban or rivaroxaban (DOACs) should be commenced first line. If neither apixaban nor
rivaroxaban are suitable then use:

• LMWH for 5 days followed by dabigatran or endoxaban or

• LMWH followed by vitamin K antagonist (VKA, i.e., warfarin)

NICE now recommend using a DOAC once diagnosis is suspected with this continued if PE is
confirmed.

• If Patient has Active Cancer, DOAC should be first line unless contraindicated.
• If patient has severe renal impairment e.g., <15/min, then use LMWH, unfractionated
heparin, LMWH followed by VKA.

Length of Anticoagulation
Length of anticoagulation should be decided on whether the PE was provoked or
unprovoked. Provoked PE is due to an obvious precipitating event e.g., immobilization
after surgery, mild thrombophilia.

• If provoked: 3 months
 • If unprovoked: 6 months

NICE recommend that whether the patient has 3 or 6 months of anticoagulation therapy, should
be based upon balancing the risk of bleeding and recurrence of venous thromboembolism.

If Patient is Hemodynamically Unstable

• Thrombolysis is first-line treatment where there is circulatory failure (e.g.,
hypotension).
• Start continuous unfractionated heparin.

Patients with recurrent pulmonary embolism while on anticoagulation, may be considered for
inferior vena cava (IVC) filters. This works by stopping the clots reaching towards lungs
formed in the deep veins of legs.