Date Published: 2/10/2025
Pulmonary embolism (PE) is a significant cause of cardiovascular mortality, presenting a unique challenge for hospitalists. Effective PE management relies on rapid risk stratification, judicious use of diagnostic testing, and appropriate treatment selection. This guide provides hospitalists with key insights into the management of pulmonary embolism, from initial diagnosis to treatment selection and disposition. Early diagnosis and treatment are crucial to improving outcomes, and a systematic approach can help navigate the complexities of PE care.
Pulmonary embolism is a critical concern for hospitalists, responsible for approximately 40,000 deaths annually in the US. Mortality risk is directly correlated with hemodynamic stability at presentation, highlighting the importance of initial assessment. An increase in PE diagnoses is observed due to heightened physician vigilance and the widespread use of CT imaging. Given the variable outcomes, early diagnosis and treatment initiation are crucial for improving patient outcomes. Risk stratification should be performed immediately upon diagnosis to guide management.
This combination has a negative likelihood ratio of 0 with an upper 95% CI of 0.06, making it a powerful tool for excluding PE. The sensitivity of D-dimer assays varies: ELISA has a sensitivity of approximately 90%, while latex immunoassays offer a sensitivity of around 96%. It’s critical to understand that false-positive D-dimer results are common, which limits its utility as a standalone test. D-dimer testing should only be used after establishing pre-test probability, and clinical assessment must be completed before, not after, reviewing D-dimer results to ensure appropriate clinical judgment is maintained.
Several risk factors contribute significantly to the likelihood of developing PE. Active cancer with chemotherapy carries an odds ratio (OR) of 6.5, while active cancer without chemotherapy carries an OR of 4.1. Neurologic disease with leg paresis presents an OR of 3.0, similar to the use of oral contraceptives, which also has an OR of 3.0. Hormone replacement therapy is associated with an OR of 2.7. Understanding these risk factors allows for more accurate risk assessment.
Age greater than 63 years independently increases PE risk. On an electrocardiogram (ECG), signs of acute right ventricular overload increase the probability of PE. The classic but nonspecific S1Q3T3 pattern and right bundle branch block may be present in some patients. T-wave inversion across precordial leads can also be observed. A normal ECG does not exclude PE, but it does impact probability assessment and should be considered within the broader clinical picture.
While chest x-ray findings in PE are not specific, they can provide valuable information, especially to rule out alternative diagnoses. Common findings include an elevated hemidiaphragm and pleural effusion. Hampton's hump, a wedge-shaped peripheral opacity, is specific but uncommon. Westermark's sign, indicating regional oligemia, is highly specific when present. Platelike atelectasis may also be seen. A normal chest x-ray does not exclude PE, but it does contribute to the overall assessment of risk and diagnosis.
Early indicators of deterioration include RV dilation and increased wall tension. The progression of RV dysfunction can lead to neurohormonal activation and RV ischemia, further complicating the clinical picture. The RV/LV ratio on CT or echocardiogram serves as a crucial marker for monitoring disease progression. Significant RV compromise is nearly universal in high-risk PE, making serial assessment of RV function vital in guiding treatment decisions.
High-risk PE is characterized by sustained hypotension with systolic blood pressure (SBP) less than 90 mmHg or shock. Intermediate-risk requires either evidence of RV dysfunction or elevated cardiac biomarkers. Low-risk patients have both normal RV function and normal biomarkers. The Pulmonary Embolism Severity Index (PESI) score is also a useful tool for refining risk assessment. It is important to remember that a patient's risk category can change during hospitalization, necessitating ongoing risk assessment.
The risk of intracranial hemorrhage is 4.6 times higher with systemic thrombolysis compared to anticoagulation alone. Bleeding risk is particularly elevated in patients over 65 years of age. Reduced-dose protocols have been explored as a method to potentially lower bleeding risk without compromising efficacy. Contraindications must be thoroughly assessed before thrombolysis administration and when available alternative interventions should always be considered.
