Venous thromboembolism: diagnosis and management of pulmonary embolism

Cindy H Lee, Graeme J Hankey, Wai Khoon Ho and John W Eikelboom
Med J Aust 2005; 182 (11): 569-574.


  • Pulmonary embolism (PE) affects 0.5–1 per 1000 people in the general population each year, and is one of the most common preventable causes of death among hospitalised patients.

  • The clinical diagnosis of PE is unreliable and must be confirmed objectively with ventilation perfusion scanning or computed tomography pulmonary angiography.

  • The diagnosis of PE can be reliably excluded, without the need for diagnostic imaging, if the clinical pretest probability for PE is low and the D-dimer assay result is negative.

  • The initial treatment of PE is low-molecular-weight heparin or unfractionated heparin for at least 5 days, followed by warfarin (target international normalised ratio [INR], 2.0–3.0) for at least 3–6 months. Patients with a high clinical pretest probability of PE should commence treatment immediately while awaiting the results of the diagnostic work-up.

  • Thrombolysis is indicated for patients with objectively confirmed PE who are haemodynamically unstable.

  • Percutaneous transcatheter or surgical embolectomy may be life-saving in patients ineligible for, or unresponsive to, thrombolytic therapy.

  • Unresolved issues in the management of venous thromboembolism include the roles of thrombophilia testing, thrombolysis for the treatment of stable PE patients who present with right ventricular dysfunction, and new anticoagulants; and the duration of anticoagulation for first unprovoked venous thromboembolism.

Please login with your free MJA account to view this article in full

  • Cindy H Lee1
  • Graeme J Hankey2
  • Wai Khoon Ho3
  • John W Eikelboom4

  • 1 Royal Perth Hospital, Perth, WA.
  • 2 Department of Medicine, McMaster University, Hamilton, Ontario, Canada.


  • 1. Fedullo PF. Pulmonary thromboembolism. In: Murray JF, Nadel JA, Mason RJ, Boushey HA, editors. Textbook of respiratory medicine. 3rd ed. Philadelphia: WB Saunders Company, 2000: 1503-1531.
  • 2. Silverstein MD, Heit JA, Mohr DN, et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med 1998; 158: 585-593.
  • 3. Ho WK, Hankey GJ, Lee CH, Eikelboom JW. Venous thromboembolism: diagnosis and management of deep venous thrombosis. Med J Aust 2005; 182: 476-481. <MJA full text>
  • 4. Goldhaber S. Pulmonary embolism. Lancet 2004; 363: 1295-1305.
  • 5. Chunilal SD, Eikelboom JW, Attia J, et al. Does this patient have pulmonary embolism? JAMA 2003; 290: 2849-2858.
  • 6. Millar AC. Suspected pulmonary embolism. Clin Med 2004; 4: 215-219.
  • 7. Dalen JE. Pulmonary embolism: what have we learned since Virchow? Chest 2002; 122: 1440-1456.
  • 8. Wood K. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of haemodynamically significant pulmonary embolism. Chest 2002; 121: 877-905.
  • 9. Grifoni S, Olivotto I, Cecchini P, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation 2000; 101: 2817-2822.
  • 10. Goldhaber S, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353: 1386-1389.
  • 11. Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med 2001; 135: 98-107.
  • 12. Kelly J, Hunt BJ. A clinical probability assessment and D-dimer measurement should be the initial step in the investigation of suspected venous thromboembolism. Chest 2003; 124: 1116-1119.
  • 13. Pistolesi M, Miniati M. Imaging techniques in treatment algorithms of pulmonary embolism. Eur Respir J 2002; 19 (Suppl 35): 28S-39S.
  • 14. Riedel M. Diagnosing pulmonary embolism. Postgrad Med J 2004; 80: 309-319.
  • 15. Qanadli SD, Hajjam ME, Mesurolle B, et al. Pulmonary embolism detection: prospective evaluation of dual-section helical CT versus selective pulmonary arteriography in 157 patients. Radiology 2000; 217: 447-455.
  • 16. Goldhaber S, Elliot G. Acute pulmonary embolism: part 1. Epidemiology, pathophysiology and diagnosis. Circulation 2003; 108: 2726-2729.
  • 17. Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med 2004; 140: 589-602.
  • 18. Kearon C. Natural history of venous thromboembolism. Circulation 2003; 107 (Suppl 1): I22-I30.
  • 19. Ribeiro A, Lindmarker P, Johnsson H, et al. Pulmonary embolism — one year follow-up with echocardiography doppler and five-year survival analysis. Circulation 1999; 99: 1325-1330.
  • 20. Pengo V, Lensing AW, Prins MH, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004; 350: 2257-2264.
  • 21. National Health and Medical Research Council. A guide to the development, implementation, and evaluation of clinical practice guidelines. Canberra: NHMRC, 1999.
  • 22. McRae S, Ginsberg J. Initial treatment of venous thromboembolism. Circulation 2004; 110 (Suppl 1): I3-I9.
  • 23. Quinlan DJ, McQuillan A, Eikelboom JW. Low-molecular-weight heparin compared with intravenous unfractionated heparin for the treatment of pulmonary embolism: a meta-analysis of randomized controlled trials. Ann Intern Med 2004; 140; 175-183.
  • 24. Hirsh J, Raschke R. Heparin and low-molecular-weight heparin. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 188S-203S.
  • 25. Levine MN, Raskob G, Beyth RJ, et al. Hemorrhagic complications of anticoagulant treatment. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 287S-310S.
  • 26. Wan S, Quinlan DJ, Agnelli G, Eikelboom JW. Thrombolysis compared with heparin for initial treatment of pulmonary embolism: a meta-analysis of randomized controlled trials. Circulation 2004; 110: 744-749.
  • 27. Dalen JE, Alpert JS, Hirsh J. Thrombolytic therapy for pulmonary embolism: is it effective? Is it safe? When is it indicated? Arch Intern Med 1997; 157: 2550-2556.
  • 28. Augustinos P, Ouriel K. Invasive approaches to treatment of venous thromboembolism. Circulation 2004; 110 (Suppl 1): I27-I34.
  • 29. Kearon C. Long term management of patients after venous thromboembolism. Circulation 2004; 110 (Suppl 1): I10-I18.
  • 30. Buller HR, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (3 Suppl): 401S-428S.
  • 31. Goldhaber S, Elliot C. Acute pulmonary embolism: part II: risk stratification, treatment, and prevention. Circulation 2003; 108: 2834-2838.
  • 32. Crowther MA, Ginsberg JS, Julian J, et al. A comparison of two intensities of warfarin for prevention of recurrent thrombosis in patients with antiphospholipid antibody syndrome. N Engl J Med 2003; 349: 1133-1138.
  • 33. Greaves M, Cohen H, Machin SJ, Mackie I. Guidelines on the investigation and management of the antiphospholipid syndrome. Br J Haematol 2000; 109: 704-715.
  • 34. Lee AY, Levine MN, Baker RI, et al; Randomized Comparison of Low-Molecular-Weight Heparin versus Oral Anticoagulant Therapy for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer (CLOT) Investigators. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 2003; 349: 146-153.
  • 35. Ridker PM, Goldhaber SZ, Danielson E, et al. Long-term, low intensity warfarin therapy for prevention of recurrent venous thromboembolism. N Engl J Med 2003; 348: 1425-1434.
  • 36. Kearon C, Ginsberg JS, Kovacs MJ, et al. Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism. N Engl J Med 2003; 349: 631-639.
  • 37. Weitz JI, Middeldorp S, Heit JA. Thrombophilia and new anticoagulant drugs. Haematology (Am Soc Hematol Educ Program) 2004; 424-438.
  • 38. Lopez JA, Kearon C, Lee AYY. Deep vein thrombosis. Haematology (Am Soc Hematol Educ Program) 2004; 439-456.
  • 39. Weitz JI. New anticoagulants for treatment of venous thromboembolism. Circulation 2004; 110 (Suppl 1): I19-I26.
  • 40. Brighton T. The direct thrombin inhibitor melagatran/ximelagatran. Med J Aust 2004; 181: 432-437. <MJA full text>


remove_circle_outline Delete Author
add_circle_outline Add Author

Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Responses are now closed for this article.