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Pulmonary Embolism (PE)

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General Information

Description

Also called

  • pulmonary thromboembolism
  • venous thromboembolism (VTE)

Definitions

  • American Heart Association classification of pulmonary embolism2
    • massive pulmonary embolism (PE) - acute PE with any of the following
      • sustained hypotension
        • systolic blood pressure < 90 mm Hg for ≥ 15 minutes or requiring inotropic support
        • not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular (LV) dysfunction
      • persistent profound bradycardia (heart rate < 40 beats per minute with signs or symptoms of shock)
      • pulselessness
    • submassive PE - acute PE without systemic hypotension (systolic blood pressure ≥ 90 mm Hg) but with either right ventricular (RV) dysfunction or myocardial necrosis
      • ventricular dysfunction includes ≥ 1 of
        • RV dilation defined as apical 4-chamber RV diameter divided by left ventricular diameter > 0.9 or RV systolic dysfunction on echocardiography
        • RV dilation defined as 4-chamber RV diameter divided by left ventricular diameter > 0.9 on computed tomography
        • brain natriuretic peptide (BNP) > 90 pg/mL
        • N-terminal pro-BNP > 500 pg/mL
        • electrocardiographic changes including new complete or incomplete right bundle-branch block, anteroseptal ST elevation or depression, or anteroseptal T-wave inversion or S1Q3 sign
      • myocardial necrosis includes either of
        • troponin I > 0.4 ng/mL
        • troponin T > 0.1 ng/mL
    • low-risk PE - acute PE without clinical markers of adverse prognosis that define massive or submassive PE
  • 2014 European Society of Cardiology (ESC) classification of pulmonary embolism1
    • high-risk pulmonary embolism defined as both
      • hemodynamic instability with shock or hypotension
      • signs of right ventricular dysfunction on imaging test, defined as ≥ 1 of
        • evidence of RV dilation and/or increased end-diastolic RV to LV diameter ratio > 0.9-1 on echocardiography
        • hypokinesia of free RV wall on echocardiography
        • increased velocity of tricuspid regurgitation jet on echocardiography
        • increased end-diastolic RV to LV diameter ratio > 0.9-1 on computed tomography (CT) angiography 4-chamber view
    • intermediate risk (without shock or hypotension)
      • intermediate-high risk pulmonary embolism defined as all of
        • Pulmonary Embolism Severity Index (PESI) class III-V or simplified PESI (sPESI) ≥ 1
        • signs of right ventricular dysfunction on imaging test
        • positive cardiac laboratory biomarker, including ≥ 1 of
          • marker of myocardial injury (for example, elevated plasma cardiac troponin I or T)
          • marker of heart failure due to RV dysfunction (for example, elevated plasma natriuretic peptide)
      • intermediate-low risk pulmonary embolism defined as PESI class III-V or sPESI ≥ 1 and either
        • one of signs of RV dysfunction on imaging or positive cardiac biomarkers
        • no signs of RV dysfunction or positive cardiac biomarkers
    • low-risk defined as absence of all of the following
      • shock or hypotension
      • PESI class III-V or sPESI ≥ 1
      • signs of RV dysfunction on imaging (assessment optional)
      • positive cardiac biomarkers (assessment optional)

Types

  • types of emboli1
    • thromboembolism
    • septic embolism
    • venous air embolism
    • fat embolism
    • amniotic fluid embolism
    • tumor embolism
    • foreign material embolism (for example, silicone, broken catheters, guide wires, vena cava filters, embolization coils, and endovascular stent components)

References

General references used

  1. Konstantinides S, Torbicki A, Agnelli G, et al; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014 Nov 14;35(43):3033-73OpenInNewfull-textOpenInNew
  2. Jaff MR, McMurtry MS, Archer SL, et al.; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, American Heart Association Council on Peripheral Vascular Disease, American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011 Apr 26;123(16):1788-830OpenInNew
  3. Goldhaber SZ, Bounameaux H. Pulmonary embolism and deep vein thrombosis. Lancet. 2012 May 12;379(9828):1835-46OpenInNew
  4. Busse LW, Vourlekis JS. Submassive pulmonary embolism. Crit Care Clin. 2014 Jul;30(3):447-73OpenInNew
  5. Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of Patients with Suspected Acute Pulmonary Embolism: Best Practice Advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015 Nov 3;163(9):701-1OpenInNewfull-textOpenInNew

Recommendation grading systems used

  • American College of Chest Physicians (ACCP) grades
    • Grade 1 - strong recommendation based on clear risk/benefit balance
    • Grade 2 - weak recommendation based on unclear or close risk/benefit balance
    • Grade A - high-quality evidence based on consistent evidence from randomized trials without important limitations or exceptionally strong evidence from observational studies
    • Grade B - moderate-quality evidence based on randomized trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise results) or very strong evidence from observational studies
    • Grade C - low- or very low-quality evidence based on evidence for ≥ 1 critical outcome from observational studies, case series, or randomized trials with serious flaws or indirect evidence
    • Reference - ACCP evidence-based clinical practice guideline on methodology for development of antithrombotic therapy and prevention of thrombosis (22315256Chest 2012 Feb;141(2 Suppl):53SOpenInNewfull-textOpenInNew), commentary can be found in 23546508Chest 2013 Apr;143(4):1190OpenInNew
  • European Society of Cardiology (ESC) grading system for recommendations
    • classes of recommendations
      • Class I - evidence and/or general agreement that given treatment or procedure is beneficial, useful, and effective
      • Class II - conflicting evidence and/or divergence of opinion about usefulness/efficacy of given treatment or procedure
        • Class IIa - weight of evidence/opinion in favor of usefulness/efficacy
        • Class IIb - usefulness/efficacy less well-established by evidence/opinion
      • Class III - evidence or general agreement that given treatment or procedure is not useful/effective, and in some cases may be harmful
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or large nonrandomized studies
      • Level C - consensus of opinion of experts and/or small studies, retrospective studies, registries
    • References
  • American Heart Association (AHA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
    • Reference - American Heart Association (AHA) scientific statement on management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension (21422387Circulation 2011 Apr 26;123(16):1788OpenInNew)
  • British Committee for Standards in Haematology (BCSH) guideline grading system
    • strength of recommendation
      • Grade 1 - strong recommendation, confidence that benefits do or do not outweigh harm and burden, can be applied uniformly to most patients
      • Grade 2 - weak recommendation, magnitude of benefit or not is less certain, requires judicious application
    • quality of evidence
      • A - high, high-quality randomized clinical trials, further research very unlikely to change confidence in estimate of effect
      • B - moderate, further research may well have important impact on confidence in estimate of effect and may change estimate
      • C - low, further research likely to have important impact on confidence in estimate of effect and likely to change estimate
    • Reference - BCSH clinical guidelines for testing heritable thrombophilia (20128794Br J Haematol 2010 Apr;149(2):209OpenInNew)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • Choosing Wisely Canada acknowledges dissemination of their recommendations through DynaMed Plus to reach the point of clinical decision-making.
  • The Canadian Association of Nuclear Medicine provides review for the incorporation of Choosing Wisely Canada recommendations.
On behalf of the American College of Physicians
  • Barbara Turner, MD, MSEd, MACP, ACP Deputy Editor, Clinical Decision Resource, as part of the ACP-EBSCO Health collaboration, managed the ACP peer review of the Overview and Recommendations section and related clinical content in this topic.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T115857, Pulmonary Embolism (PE); [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T115857. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • KeyboardArrowRight

      Evaluation

      • Suspected pulmonary embolism with sustained hypotension

      • Suspected pulmonary embolism without sustained hypotension

      • Further evaluation after the diagnosis is made

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

    • Definitions

    • Types

  • KeyboardArrowRight

    Epidemiology

    • KeyboardArrowRight

      Incidence/Prevalence

      • General population

      • Hospitalized patients

      • Delivery and Postpartum Period

      • Children

    • Risk factors

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Family history (FH)

      • Social history (SH)

    • KeyboardArrowRight

      Physical

      • General physical

      • Skin

      • Chest

      • Lungs

      • Extremities

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • KeyboardArrowRight

      Testing overview

      • Testing to consider to diagnose or rule out PE

      • Testing to consider upon diagnosing PE

    • Clinical prediction rules

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      Blood tests

      • Arterial blood gases (ABGs)

      • D-dimer testing

      • Other blood tests

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      Imaging studies

      • Chest x-ray

      • Computed tomography (CT) angiography (spiral or helical CT angiography)

      • Computed tomography venography of lower extremities

      • Ventilation/Perfusion lung scan (V/Q scan)

      • Perfusion lung scan without ventilation scan

      • Comparing CT pulmonary angiography vs. ventilation-perfusion (V/Q) scan

      • Pulmonary angiography

      • Ultrasound

      • Magnetic resonance angiography (MRA)

      • Echocardiogram

    • Electrocardiography (ECG)

    • KeyboardArrowRight

      Other diagnostic testing

      • Exhaled end-tidal ratio of carbon dioxide to oxygen

      • Alveolar dead-space fraction

      • KeyboardArrowRight

        Diagnostic guidelines

        • American Academy of Family Physicians/American College of Physicians (AAFP/ACP)

        • European Society of Cardiology (ESC)

        • Guideline-adherent diagnostic management

  • KeyboardArrowRight

    Management

    • Management overview

  • KeyboardArrowRight

    Complications and Prognosis

    • KeyboardArrowRight

      Complications

      • Complications of pulmonary embolism

      • Complications of therapies for pulmonary embolism

    • KeyboardArrowRight

      Prognosis

      • Mortality risk

      • KeyboardArrowRight

        Tools for predicting mortality

        • Pulmonary embolism severity index (PESI)

        • Simplified PESI (sPESI)

        • European Society of Cardiology model

        • Other prognostic tools to determine mortality risk

      • Predicting morbidity

      • Morbidity risk

      • Computed tomography (CT) for prognosis

      • Lung scan for prognosis

      • Echocardiography for prognosis

  • KeyboardArrowRight

    Prevention and Screening

    • Prevention

    • Screening

  • KeyboardArrowRight

    Quality Improvement

    • Medicare/Joint Commission National Hospital Inpatient Quality Measures

    • Choosing Wisely

    • Choosing Wisely Australia

    • Choosing Wisely Canada

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Mexican guidelines

      • Central and South American Guidelines

      • Australian and New Zealand guidelines

      • Middle Eastern guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Shyoko Honiden MD, MSc
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Affiliations

Associate Professor in the Clinical Educator Track, Section of Pulmonary and Critical Care Medicine, Fellowship Program Director, Pulmonary and Critical Care Fellowship, and Director of Simulation, Department of Medicine, Yale University School of Medicine; Connecticut, United States

Conflicts of Interest

Dr. Honiden declares no relevant financial conflicts of interest.

Recommendations Editor
Zbys Fedorowicz MSc, DPH, BDS, LDSRCS
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Affiliations

Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain

Conflicts of Interest

Dr. Fedorowicz declares no relevant financial conflicts of interest.

Recommendations Editor
Amir Qaseem MD, PhD, MHA, FACP
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Affiliations

Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network; Germany

Conflicts of Interest

Dr. Qaseem declares no relevant financial conflicts of interest.

Deputy Editor
Terence K. Trow MD, FACP, FCCP
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Affiliations

Deputy Editor of Pulmonary, Critical Care, and Sleep Medicine; Connecticut, United States; Ex-Director of the Yale Pulmonary Vascular Disease Program, Associate Clinical Professor of Medicine, Yale University School of Medicine; Connecticut, United States

Conflicts of Interest

Dr. Trow declares no relevant financial conflicts of interest.

ACP Reviewer
Daniel J. Brotman MD, FACP, MHM
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Affiliations

Professor of Medicine, John Hopkins University; Maryland, United States; Director, John Hopkins Hospital Hospitalist Program; Maryland, United States

Conflicts of Interest

Dr. Brotman declares relevant financial relationships with Pfizer and Portola (Advisory Board/Committee).

Produced in collaboration with American College of Physicians

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CT pulmonary angiogram

CT pulmonary angiogram

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