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Pulmonary embolism: update on diagnosis and management

Paul C Kruger, John W Eikelboom, James D Douketis and Graeme J Hankey
Med J Aust 2019; 211 (2): . || doi: 10.5694/mja2.50233
Published online: 15 July 2019

Summary

  • Pulmonary embolism (PE) is a potentially life‐threatening condition, mandating urgent diagnosis and treatment.
  • The symptoms of PE may be non‐specific; diagnosis therefore relies on a clinical assessment and objective diagnostic testing.
  • A clinical decision rule can determine the pre‐test probability of PE. If PE is “unlikely”, refer for a D‐dimer test. If the D‐dimer result is normal, PE can be excluded. If D‐dimer levels are increased, refer for chest imaging. If PE is “likely”, refer for chest imaging.
  • Imaging with computed tomography pulmonary angiogram is accurate and preferred for diagnosing PE, but may detect asymptomatic PE of uncertain clinical significance.
  • Imaging with ventilation–perfusion (VQ) scan is associated with lower radiation exposure than computed tomography pulmonary angiogram, and may be preferred in younger patients and pregnancy. A low probability or high probability VQ scan is helpful for ruling out or confirming PE, respectively; however, an intermediate probability VQ scan requires further investigation.
  • The direct oral anticoagulants have expanded the anticoagulation options for PE. These are the preferred anticoagulant for most patients with PE because they are associated with a lower risk of bleeding, and have the practical advantages of fixed dosage, no need for routine monitoring, and fewer drug interactions compared with vitamin K antagonists. Initial parenteral treatment is required before dabigatran and edoxaban.
  • Paul C Kruger1,2,3
  • John W Eikelboom3,4
  • James D Douketis4,5
  • Graeme J Hankey6

  • 1 Fiona Stanley Hospital, Perth, WA
  • 2 PathWest Laboratory Medicine, Perth, WA
  • 3 Population Health Research Institute, Hamilton, Canada
  • 4 Hamilton Health Sciences, Hamilton, Canada
  • 5 St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, Canada
  • 6 University of Western Australia, Perth, WA

Correspondence: graeme.hankey@uwa.edu.au

Competing interests:

No relevant disclosures.

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