Recent developments in the diagnosis and treatment of pulmonary embolism

• Published in: Journal of internal medicine Vol. 279; no. 1; pp. 16 - 29
• Main Authors: Hulle, T., Dronkers, C. E. A., Klok, F. A., Huisman, M. V.
• Format: Journal Article
• Language: English
• Published: England 01.01.2016
• Subjects: Aged, 80 and over; Anticoagulants - therapeutic use; anticoagulation; diagnosis; Diagnostic Imaging; Fibrin Fibrinogen Degradation Products - analysis; Heparin, Low-Molecular-Weight; Humans; pulmonary embolism; Pulmonary Embolism - diagnosis; Pulmonary Embolism - drug therapy; Thrombolytic Therapy; treatment; venous thromboembolism; Vitamin K - antagonists & inhibitors; treatment; diagnosis; pulmonary embolism; venous thromboembolism; anticoagulation
• ISSN: 0954-6820; 1365-2796
• DOI: 10.1111/joim.12404

Due to the nonspecific symptoms of the condition, a diagnosis of acute pulmonary embolism (PE) is frequently considered. However, PE will only be confirmed in 10–20% of patients. Because the imaging test of choice, computed tomography pulmonary angiography (CTPA), is costly and associated with radiation exposure and other complications, a validated diagnostic algorithm consisting of a clinical decision rule and D‐dimer test should be used to safely exclude PE in 20–30% of patients without the need for CTPA. Recently, the age‐adjusted D‐dimer threshold has been validated, and this has increased the proportion of patients at older age in whom PE can be excluded without CTPA. Initial therapeutic management of PE depends on the risk of short‐term PE‐related mortality. Haemodynamically unstable patients should be closely monitored and receive thrombolytic therapy unless contraindicated because of an unacceptably high bleeding risk, whereas patients with low‐risk PE may be safely discharged early from hospital or receive only outpatient treatment. The PESI score and Hestia decision rule are available to select patients in whom early discharge or outpatient treatment will be safe, although the safety of these strategies should be confirmed in additional studies. Standard PE therapy consists of low molecular weight heparin (LMWH) followed by vitamin K antagonists (VKAs). Recently, several nonvitamin K‐dependent oral anticoagulants have been shown to be as effective as LMWH/VKAs, and maybe safer. Determining the optimal duration of treatment for a first unprovoked PE remains a challenge, although clinical prediction rules for estimating the risk of recurrence of venous thromboembolism and anticoagulation‐associated haemorrhage are under investigation. Using these prediction rules may lead to both more standardized and more individualized long‐term treatment of PE.