Pulmonary Embolism

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Quick reference

2026 Guidelines

• 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines | Circulation

PRINTABLE PERT CHEAT SHEET

Evaluation

EKG

• [PE EKG Findings](Is this ECG easy for you yet? - Dr. Smith’s ECG Blog)
• EMCrit Wee - ECGs in Acute Pulmonary Embolism - Death Threats in Little Squiggly Lines

Simultaneous T-Wave Inversions in V1-4 AND III/AVF (anterior and inferior leads)

• Pattern: little R, big S, coved ST, bit TWI
• Sinus Tachycardia
• S1Q3T3
• Ultrasound (McConnell’s, D sign, etc)

Scores

Well’s

• Low Risk: PERC
• Intermediate: D-Dimer / YEARS
• High: CTPA

Wells’ Criteria for Pulmonary Embolism
PERC Rule for Pulmonary Embolism
YEARS Algorithm for Pulmonary Embolism (PE)
Age-Adjusted D-dimer for Venous Thromboembolism (VTE)

History and Physical Exam

Symptoms:

Especially concerning:
Tachycardia + hypotension = likely RV dysfunction
Tachypnea + hypoxemia = significantly impaired VQ

• one of four key symptoms are present in 94% of patients
  • sudden onset dyspnea
  • pleuritic chest pain (especially concerning when localizable)
  • syncope
  • hemoptysis
• Tachycardia (heart rate >100/min) occurs in 65-70% of PE patients
• Hemoptysis, though present in only 5-13% of patients with PE, is a particularly specific finding
• Clinical signs of DVT (including unilateral leg swelling, tenderness, and prominent collateral veins) are present in approximately 40% of symptomatic PE patients and substantially raise the probability of diagnosis.

Risk factors:
- Recent surgical procedures (especially orthopedic).
- Recent hospitalization for heart failure or MI.
- Prior venous thromboembolic disease.
- Malignancy (especially metastatic).
- Postpartum (especially after C-section).
- Estrogen-containing oral contraceptives, hormone replacement therapy, in vitro fertilization.
- Older age.
- Immobility.
- Thrombophilia (including autoimmune diseases, inflammatory bowel disease, infection).

• Approach to PE diagnosis: (https://emcrit.org/ibcc/pulmonary-embolism/#approach_to_PE_diagnosis)

PE Severity

Additional Initial Workup by Clinical Category

Determine Severity
Pulmonary Embolism Severity Index (PESI)
Simplified PESI (Pulmonary Embolism Severity Index)

• Category A / B:

1. severity score (PESI / sPESI)

• Category C / D:

1. RV imaging (CT or TTE)
2. cardiac biomarker (troponin)
3. lactate

Treatment

Anticoagulation: All Categories

• A: DOAC
• C/D/E1: LMWH
• E2: LMHW / UFH

Advanced Therapies: D1 / D2 / E2

• Thrombectomy
  • D1/D2/E1: MT acceptable
• Systemic Thrombolysis
  • D/E: TPA
• Supportive / Adjunctive Care
  • VA-ECMO: E1/2

Duration:

• Provoked/Reversible risk factors: 3-6 months

• Unprovoked / irreversible risk factors: prolonged therapy

Disposition

A: outpatient treatment with DOAC
B: sPESI/PESI - Outpt / CDU (obs)
C:

• C1: floor
• C2/3: IMC
  D/E: ICU

Special Populations

Pregnancy:

• Use LMWH
• AVOID DOACs and VKAs
• Low-dose CTPA > VQ scan
• VQ SPECT > Planar VQ

Breastfeeding:

• Use LMWH
• AVOID DOACs

Obesity

• DOACs preferred

CKD:

• CrCl 30-89: DOACs safe
• CrCl <15: Apixaban?

Hepatic Impairment

• Child-Pugh A/B: DOACs safe
• Child-Pugh C: Avoid DOACs

APL:

• VKAs preferred (especially for “triple positive” patients)

Brain Tumors

• DOACs preferred