Despite significant clinical and scientific advancements, pulmonary embolism remains a challenge to diagnose and manage. Evidence-based guidelines address the intricacies, but recommendations can vary and appear inconsistent, potentially complicating the management pathway. Here, Dr Marco Zuin shares personal experience and key guideline recommendations for managing the condition according to international standards.
As a cardiovascular specialist, I have witnessed first-hand the challenges and complexities of managing acute pulmonary embolism. It is a condition that demands rapid, decisive action, a keen understanding of risk stratification and a willingness to adapt treatment strategies based on the individual patient’s needs.
Pulmonary embolism remains a leading cause of cardiovascular mortality. However, its timely recognition can be challenging. It is estimated that around 20% of patients with the condition are diagnosed more than 10 days after the onset of symptoms.1 As it can be fatal if untreated, prompt and accurate diagnosis is crucial.2
Turning to evidence-based clinical practice guidelines can support the diagnosis and management of pulmonary embolism, but heterogeneity in recommendations can lead to uncertainty. In a recent review of international PE guidelines, we highlighted key areas of consistency and divergence, emphasising critical clinical and research needs.
The pulmonary embolism diagnostic journey
Early diagnosis of pulmonary embolism is emphasised by many of the major guidelines. The diagnostic approach begins with a comprehensive patient assessment. As clinicians, we utilise validated tools, such as the Wells Score3 or Geneva Score,4 to determine the pre-test probability of pulmonary embolism.
In patients with low pre-test probability and negative D-dimer results, we can confidently exclude pulmonary embolism. However, imaging becomes essential in cases with elevated D-dimer levels or high pre-test probability.
Computed tomographic pulmonary angiography (CTPA) remains the gold-standard imaging modality for acute pulmonary embolism diagnosis, providing detailed visualisation of the pulmonary vasculature.5 However, alternative approaches, such as V/Q scanning or bedside echocardiography can be valuable in haemodynamically unstable patients when CTPA is not feasible or is contraindicated.5
Risk stratification to guide treatment decisions
Once a diagnosis is confirmed, risk stratification becomes critical.5 Validated tools, such as the Pulmonary Embolism Severity Index (PESI)6 are used. The PESI score is complex and based on 11 different variables, so a simplified version known as sPESI, which evaluates six variables, is also used to categorise patients into low-, intermediate- or high-risk groups.7
However, these tools have limitations. While PESI and sPESI accurately identify one-third of low-risk patients with acute symptomatic PE, they may overestimate the risk for some patients. Indeed, both scores exhibit only moderate discriminative ability, and may misclassify patients. For instance, sPESI tends to overestimate risk, potentially leading to unnecessary hospitalisations for some low-risk individuals. Furthermore, PESI and sPESI rely on clinical variables that may not fully capture the heterogeneity of intermediate-risk patients, who might benefit from more advanced risk stratification methods incorporating biomarkers or imaging.
These limitations highlight the need for integrating broader clinical information and developing improved predictive models for pulmonary embolism management.
Anticoagulation is the cornerstone of treatment across all risk levels. Empiric therapeutic anticoagulation should be initiated while awaiting diagnostic results for patients with suspected pulmonary embolism and an intermediate or high pre-test probability.
- Low-risk patients
According to the European Society of Cardiology (ESC) guidelines,8 direct oral anticoagulants have transformed treatment protocols for low-risk patients. They offer home treatment and an efficient, predictable management strategy that is non-inferior to vitamin K antagonists while being associated with a lower risk of bleeding.
- Intermediate-risk patients
Patients at intermediate risk present a greater challenge.
The ESC guidelines classify these patients as intermediate-low risk in the presence of a right ventricular dysfunction or biomarker elevation, but not both, or intermediate-high risk in the presence of a right ventricular dysfunction and biomarker elevation.8
For intermediate-low risk, standard anticoagulation is the initial treatment.5
When it comes to intermediate-high risk patients, treatment options beyond anticoagulation with unfractionated heparin, such as catheter embolectomy, catheter thrombolysis or surgical embolectomy, are considered due to the risk of sudden clinical deterioration, particularly within the first 48–72 hours after symptom onset.5,9
- High-risk patients
High-risk patients with pulmonary embolism, defined as those haemodynamically unstable at admission, demand aggressive intervention, including systemic thrombolysis, surgical embolectomy and, in select cases, even extracorporeal membrane oxygen therapy.5,10
In these patients, we must be meticulous in assessing contraindications to thrombolysis to prevent potentially catastrophic complications and to avoid delays in the reperfusion process.
The future of managing pulmonary embolism
As the field evolves, especially with the emergence of new catheter-based technologies, cardiovascular specialists will take on a more active role in managing patients with pulmonary embolism. We must embrace these innovations and continue to refine our treatment strategies to enhance the lives of these patients.
At the same time, we must encourage a multidisciplinary approach by creating local pulmonary embolism response teams.5 These teams, comprising experts from various specialties, collaborate to assess and develop patient treatment plans, functioning similarly to stroke or ST segment elevation myocardial infarction teams.
This strategy will promote the use of advanced diagnostic and therapeutic tools, prioritise person-centred care and continuously improve outcomes for patients with pulmonary embolism.
Author
Marco Zuin MD MS
Cardiology Unit, Department of Translational Medicine University of Ferrara and Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy
References
- Ageno W et al; MASTER Investigators. Factors associated with the timing of diagnosis of venous thromboembolism: results from the MASTER registry. Thromb Res 2008;121:751–6.
- Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest 2002;121:877–905.
- Wells PS 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.
- Le Gal G et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 2006;144:165–71.
- Zuin M et al. International Clinical Practice Guideline Recommendations for Acute Pulmonary Embolism: Harmony, Dissonance, and Silence. J Am Coll Cardiol 2024;84:1561–77.
- Aujesky D et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011;378:41–8.
- Jiménez D et al; RIETE Investigators. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010;170:1383–9.
- Konstantinides SV et al; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020;41:543–603.
- Zuin M, Becattini C, Piazza G. Early predictors of clinical deterioration in intermediate-high risk pulmonary embolism: clinical needs, research imperatives, and pathways forward. Eur Heart J Acute Cardiovasc Care 2024;13:297–303.
- Zuin M et al. Innovation in Catheter-Directed Therapy for Intermediate-High-Risk and High-Risk Pulmonary Embolism. JACC Cardiovasc Interv 2024;17:2259–73.
