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Cardiology and Cardiovascular Medicine›Condition·Updated Jun 27, 2026·v1

Pulmonary Embolism (Opus)

Acute pulmonary embolism is thromboembolic obstruction of the pulmonary arteries causing right ventricular afterload failure; diagnosis combines clinical probability, D-dimer and CT pulmonary angiography, and risk-adapted management ranges from outpatient DOAC therapy to systemic thrombolysis.

Low Evidence27 references·7,117 words·29 min read·v1
CardiologyPulmonary and Respiratory MedicineVenous Thromboembolism

Quick Reference

RxDrug of choiceApixaban or rivaroxaban (DOAC) for most; alteplase for high-risk PE; LMWH in pregnancy/cancer
AltAlternativesLMWH bridged to warfarin; dabigatran; unfractionated heparin in renal failure
⊘AvoidDOACs in pregnancy; systemic thrombolysis with active bleeding/recent intracranial haemorrhage
DxTest of choiceCT pulmonary angiography
ScKey scorePESI/sPESI; Wells; PERC; YEARS; Geneva
→When to referHemodynamic instability, intermediate-high risk with deterioration, suspected CTEPH, or pregnancy/cancer-associated PE -> PE response team.
Risk-stratify confirmed PE by haemodynamics, RV function and troponin; anticoagulate all, thrombolyse the unstable.

Overview and Recommendations

Background

  • •Acute PE is the most lethal form of venous thromboembolism, caused by embolised venous thrombi obstructing the pulmonary arteries [1][3].
  • •Death occurs through acute right ventricular afterload failure, not primarily through hypoxaemia [6].
  • •Roughly 1 in 12 people in Western populations are diagnosed with VTE in their lifetime [4].

Key Points

  • •Severity is defined by haemodynamics, RV function and troponin (ESC tiers), not clot size [11].
  • •CT pulmonary angiography is the gold standard; non-high probability plus negative D-dimer excludes PE [7][9].
  • •DOACs are first-line; systemic thrombolysis is reserved for high-risk (shock) PE [18].

Board Review — High Yield

  • •sPESI 0 - 30-day mortality ~0.5%, NPV 99.5%; identifies candidates for outpatient care [11].
  • •CTPA - gold standard confirmatory test for PE [7].
  • •D-dimer - high-sensitivity assay rule-out NPV 99-100%; never a rule-in [9].
  • •High-risk PE - shock/hypotension; systemic thrombolysis is first-line reperfusion [16][18].
  • •Intermediate-high PE - RV dysfunction PLUS elevated troponin; monitor for deterioration [11].
  • •DOAC - first-line for almost all PE; less major bleeding than warfarin [1][18].
  • •Pregnancy PE - LMWH is anticoagulant of choice; DOACs contraindicated [24].
  • •CTEPH - screen persistent post-PE dyspnoea with V/Q; potentially curable by endarterectomy [20].
  • •Unprovoked PE - consider extended reduced-dose anticoagulation [18][21].
  • •Catastrophic PE - haemodynamic collapse; in-hospital mortality ~42% [16].

Deep Dive — Evidence Details

References

  1. [1]

    Khan F, Tritschler T, Kahn SR, Rodger MA. “Venous thromboembolism” Lancet (2021). PMID: 33984268 ↗

    Review
  2. [2]

    Di Nisio M, van Es N, Buller HR. “Deep vein thrombosis and pulmonary embolism” Lancet (2016). PMID: 27375038 ↗

    Review
  3. [3]

    Huisman MV, Barco S, Cannegieter SC, et al. “Pulmonary embolism” Nat Rev Dis Primers (2018). PMID: 29770793 ↗

    Review
  4. [4]

    Lutsey PL, Zakai NA. “Epidemiology and prevention of venous thromboembolism” Nat Rev Cardiol (2022). PMID: 36258120 ↗

    Review
  5. [5]

    Shah IK, Merfeld JM, et al. “Pathophysiology and Management of Pulmonary Embolism” Int J Angiol (2022). PMID: 36157092 ↗

    Review
  6. [6]

    Giannakoulas G, et al. “Acute right ventricular failure: pathophysiology, aetiology, assessment, and management” Eur Heart J (2025). PMID: 40259766 ↗

    Review
  7. [7]

    Abdelaal Ahmed Mahmoud M Alkhatip A, et al. “YEARS Algorithm Versus Wells' Score: Predictive Accuracies in Pulmonary Embolism Based on the Gold Standard CT Pulmonary Angiography” Crit Care Med (2020). PMID: 32079894 ↗

    Diagnostic accuracy
  8. [8]

    Simon A, Amon T, et al. “Acute pulmonary embolism pretest probability estimation by d-dimer test, our modified, new ECG score and clinical prediction rules” Heliyon (2024). PMID: 39281615 ↗

    Diagnostic accuracy
  9. [9]

    Michiels JJ, et al. “Different accuracies of rapid enzyme-linked immunosorbent, turbidimetric, and agglutination D-dimer assays for thrombosis exclusion” Semin Thromb Hemost (2006). PMID: 17024595 ↗

    Review
  10. [10]

    Polo Friz H, et al. “Acute pulmonary embolism in patients presenting pulmonary deterioration after hospitalisation for non-critical COVID-19” Intern Med J (2021). PMID: 33834578 ↗

    Cohort
  11. [11]

    Becattini C, Agnelli G, Lankeit M, et al. “Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model” Eur Respir J (2016). PMID: 27174887 ↗

    Cohort validation
  12. [12]

    Goraya SR, O'Hare C, et al. “Optimizing Use of High-Sensitivity Troponin for Risk-Stratification of Acute Pulmonary Embolism” Thromb Haemost (2024). PMID: 38788767 ↗

    Cohort
  13. [13]

    Barco S, Konstantinides SV. “Risk-adapted management of pulmonary embolism” Thromb Res (2017). PMID: 28262244 ↗

    Review
  14. [14]

    Piazza G. “Advanced Management of Intermediate- and High-Risk Pulmonary Embolism: JACC Focus Seminar” J Am Coll Cardiol (2020). PMID: 33121720 ↗

    Review
  15. [15]

    Harvey JJ, Huang S, Uberoi R. “Catheter-directed therapies for the treatment of high risk and intermediate risk acute pulmonary embolism” Cochrane Database Syst Rev (2022). PMID: 35938605 ↗

    Systematic review
  16. [16]

    Kobayashi T, Pugliese S, et al. “Contemporary Management and Outcomes of Patients With High-Risk Pulmonary Embolism” J Am Coll Cardiol (2024). PMID: 38171708 ↗

    Registry cohort
  17. [17]

    Zuin M, Rigatelli G, Zonzin P, Roncon L. “Inferior Vena Cava Filters in Hemodynamically Unstable Patients with Acute Pulmonary Embolism” Cardiovasc Intervent Radiol (2019). PMID: 31093719 ↗

    Review
  18. [18]

    Duffett L, Castellucci LA, Forgie MA. “Pulmonary embolism: update on management and controversies” BMJ (2020). PMID: 32759284 ↗

    Review
  19. [19]

    Tran HA, Gibbs H, et al. “New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism” Med J Aust (2019). PMID: 30739331 ↗

    Guideline
  20. [20]

    Luijten D, et al. “Post-Pulmonary Embolism Syndrome and Functional Outcomes after Acute Pulmonary Embolism” Semin Thromb Hemost (2022). PMID: 35820428 ↗

    Review
  21. [21]

    Cox C, Roberts LN. “Basics of diagnosis and treatment of venous thromboembolism” J Thromb Haemost (2025). PMID: 39938684 ↗

    Review
  22. [22]

    Hobohm L, Lankeit M. “Pulmonary Embolism” Pneumologie (2021). PMID: 34662916 ↗

    Review
  23. [23]

    Hammache M, Simard C, et al. “Diagnosing Pulmonary Embolism During Pregnancy” Chest (2025). PMID: 40404047 ↗

    Review
  24. [24]

    Merz LE, Bassa B, Ni Ainle F, Fogerty AE. “Thrombotic complications in pregnancy: a case-based review of the evidence” J Thromb Haemost (2024). PMID: 39395543 ↗

    Review
  25. [25]

    Amerali M, Politou M. “Tinzaparin - a review of its molecular profile, pharmacology, special properties, and clinical uses” Eur J Clin Pharmacol (2022). PMID: 35871241 ↗

    Review
  26. [26]

    Buckley JR, et al. “In-Hospital Mortality and Related Outcomes for Elevated Risk Acute Pulmonary Embolism Treated With Mechanical Thrombectomy Versus Routine Care” J Intensive Care Med (2021). PMID: 34397286 ↗

    Cohort
  27. [27]

    Chopard R, et al. “Renal dysfunction improves risk stratification and may call for a change in the management of intermediate- and high-risk acute pulmonary embolism” Crit Care (2021). PMID: 33563311 ↗

    Cohort

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