The Emergency Medicine Approach To The Evaluation And Treatment Of Pulmonary Embolism
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The Emergency Medicine Approach To The Evaluation And Treatment Of Pulmonary Embolism

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Table of Contents
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal Of The Literature
  5. History And Pathophysiology
  6. Prehospital Care
  7. Emergency Department Evaluation
    1. History, Physical Examination, And Risk Stratification
  8. Diagnostic Studies
    1. Chest X-ray
    2. Electrocardiogram
    3. Arterial Blood Gas Analysis
    4. D-dimer
    5. Computerized Tomographic Pulmonary Angiography
    6. Ventilation/Perfusion Scanning
    7. Bedside Cardiac Echocardiography
    8. Venous Compression Ultrasonography
    9. Risk Stratification Post Diagnosis
  9. Treatment
    1. Systemic Anticoagulation
    2. Reperfusion Treatments
    3. Inferior Vena Cava Filters
    4. Treatment Summary
  10. Controversies And Cutting Edge
    1. Computerized Tomographic Pulmonary Angiography Versus Ventilation/Perfusion Scanning
    2. Diagnostic Testing In Pregnancy
  11. Disposition
  12. Summary
  13. Risk Management Pitfalls For Pulmonary Embolism
  14. Time- And Cost-Effective Strategies
  15. Case Conclusions
  16. Clinical Pathway For Suspected Low-Probability Pulmonary Embolism
  17. Clinical Pathway For Moderate- To High-Probability Pulmonary Embolism
  18. This Month In EM Practice Guidelines Update
  19. Tables and Figures
    1. Table 1. Venous Thromboembolic Risk Factors
    2. Table 2. Wells Score
    3. Table 3. Simplified Revised Geneva Score
    4. Table 4. Pulmonary Embolism Rule-Out Criteria (PERC)
    5. Table 5. Sensitivity And Specificity Of Clinical Gestalt, Wells Score, And Revised Geneva Score
    6. Table 6. Clinical Features From The History And Physical Examination That Predict The Presence Or Absence Of Pulmonary Embolism
    7. Table 7. Factors That Can Increase Or Decrease The Accuracy Of The D-dimer Assay In Diagnosing Pulmonary Embolism
    8. Table 8. Accuracy Of sPESI In Predicting 30-Day Mortality Among Different Risk Groups
    9. Table 9. Original And Simplified Pulmonary Embolism Severity Index (PESI)
    10. Figure 1. Electrocardigram Of Patient With Massive Pulmonary Embolism
    11. Figure 2. Association Of Thrombolytic Therapy With A Decrease In Mortality For Unstable Patients With Pulmonary Embolism
  20. References


Each year in the United States, up to 900,000 individuals will suffer from acute pulmonary embolism, resulting in an estimated 200,000 to 300,000 hospital admissions. Despite decades of research on the topic, the diagnosis remains elusive in many situations and the fatality rate remains significant. This issue presents a review of the current evidence guiding the emergency medicine approach to the diagnosis and treatment of pulmonary embolism. Key to this approach is the concept of risk stratification: using factors from the history and physical examination, plus ancillary tests, to guide clinical decision making. The pathophysiology of pulmonary embolism and decision-support tools are reviewed, and emergency department management strategies are described.

Case Presentations

A 49-year-old male construction worker presents to the ED reporting a brief loss of consciousness 30 minutes prior to arrival while climbing through a crawlspace at work. He reports a prodrome of feeling short of breath, lightheaded, and dizzy, with associated midsternal chest pain. Family members at the bedside report that he was complaining of generalized weakness with mild shortness of breath at rest and on exertion for the past 3 to 4 days. His past medical history is significant for rectal cancer treated with resection, a traumatic fracture of L3, and deep vein thrombosis 9 months ago, after which he completed a 6-month course of warfarin. The patient denies use of tobacco, alcohol consumption, or use of illicit drugs. There is no family history of any medical problems. His vital signs upon arrival are: temperature, 36°C; blood pressure, 104/79 mm Hg; heart rate, 106 beats per minute; respiratory rate, 20 breaths per minute; and oxygen saturation, 95% on room air. He is in no distress, is sitting upright on the stretcher, and is speaking in full sentences. Aside from a regular tachycardia, his exam is normal. Initial ECG shows a sinus tachycardia at 106 beats per minute, rightward axis deviation, ST-segment depressions throughout, and deep T-wave inversions in the anterolateral leads. Laboratory analysis, including cardiac markers, electrolytes, CBC, and renal function are remarkable only for a platelet count of 115,000 x 109/L. Initial cardiac markers and electrolytes are normal. You put acute coronary syndromes on the top of your differential and admit the patient to the observation unit, but you wonder if there is anything else that should be done while waiting for the second troponin...

A short time later, a 58-year-old male with a history of hypertension presents to the ED with leg pain. He woke up 2 days prior with pain and discoloration of his right leg, which has progressively worsened. Although not initially reported in the chief complaint, upon review of systems, the patient reports that he has been dizzy and short of breath for the past couple of days. He denies chest pain, diaphoresis, or syncope. The patient further denies history of coagulopathy or prior blood clots. On exam, he is well-appearing and in no distress. He is afebrile, is tachycardic at 117 beats per minute, is breathing at a rate of 16 breaths per minute, and has a blood pressure of 155/93 mm Hg. His oxygen saturation is 97% on room air. The physical exam is remarkable only for the right lower extremity. The entire right leg is diffusely tender, with edema, erythema, and plethora. Laboratory results are unremarkable; ECG is normal sinus rhythm at a rate of 98 beats per minute with left axis deviation and no ST-segment abnormalities.


Each year in the United States, it is estimated that between 600,000 and 900,000 individuals suffer from acute pulmonary embolism (PE), accounting for an estimated 200,000 to 300,000 hospital admissions.1-4 In the United States, as many as 100,000 deaths are estimated to be caused by venous thromboembolism each year. Furthermore, numerous studies have found that approximately 1% of all patients admitted to hospitals die of acute PE, and an estimated 10% of all hospital deaths are PE related.5-7 If left untreated, PE can be rapidly fatal.2,8,9

Improvements in detection and treatment of deep vein thromboses, venous thromboembolism prophylaxis protocols, and improvements in the sensitivity and specificity of diagnostic tests have resulted in a substantially decreased overall mortality from PE in the past decade.3,10 Nonetheless, despite these advancements, PE still remains a fatal pathology, with a mortality rate of up to 10% of all patients diagnosed with an acute PE in the first 1 to 3 months following diagnosis.11,12 While the mortality of PE is well publicized, the morbidity associated with undiagnosed PE is not, and it can be very disabling, leading to both pulmonary hypertension and postthrombotic syndrome.4,13-15 This issue of Emergency Medicine Practice presents a review of the current evidence guiding the emergency medicine approach to the diagnosis and treatment of PE.

Critical Appraisal Of The Literature

An extensive literature search was performed using the PubMed database, Ovid MEDLINE®, and the Cochrane Database of Systematic Reviews. Searches were limited to the English language. Search terms included, but were not limited to the following: pulmonary embolism, venous thromboembolism, emergency department, treatment, risk stratification, prevention, deep vein thrombosis, and cancer. Search results for pulmonary embolism returned 13,305 articles. The search was further limited to include only clinical trials, meta-analyses, practice guidelines, randomized controlled trials, and reviews, returning 3378 publications. The breadth of the available literature is extensive; thus, clinical trials and guidelines were only reviewed if published within the last decade. The National Guideline Clearinghouse ( and the American College of Emergency Physicians (ACEP) Clinical Policies were referenced for PE management, risk stratification, and prevention guidelines and policies. The bibliographies of these guidelines were also reviewed. A total of 98 references were used in the preparation of this article.

As noted earlier, the number of publications on the topic of PE is extensive, with articles dating back over a century and multiplying exponentially in the last decade. There has been a great expansion in the literature around PE in the last 10 to 20 years. Studies typically focus on either the diagnosis or the treatment of PE, but there are several limitations in the literature regarding both of these types of studies. Diagnostic studies are typically limited by the relatively low prevalence of PE, so maintaining high sensitivity with narrow confidence intervals often requires a multicenter trial in order to enroll enough patients. Nonetheless, several recent meta-analyses have added validity to the findings of smaller studies. An additional limitation for studies regarding the diagnosis of PE is the variability in the definition of a “true negative.” Studies vary widely regarding which “gold standard” (if any) is used to assess if the results of the diagnostic study in question are accurate. “Gold standard” tests vary from clinical follow-up to pulmonary angiography. Regarding treatment studies, the primary limitation is the lack of well-controlled studies in critically ill patients, where poor outcomes are most likely. The challenge of performing informed consent in this group is an important limitation of many studies aiming to evaluate treatment in the critically ill patient with PE. Consequently, studies evaluating the effectiveness of both medical and interventional treatments for those who are the most unstable are often small retrospective studies or large database reviews where the patient populations included in the various studies are difficult to compare or specifics regarding the patients are not available.

Risk Management Pitfalls For Pulmonary Embolism

  1. “PE wasn’t a part of this patient’s differential.”

    Consider PE in patients with the most-common complaints (chest pain and shortness of breath), but also with less-common complaints such as syncope, dizziness, or anxiety. PE can present with a multitude of complaints, and it is essential to keep a low threshold when deciding to include it in the differential.

  2. “This patient was in shock. I thought he was septic.”

    Always consider massive PE in the differential of undifferentiated atraumatic shock.

  3. “Her PERC score was negative, so I didn’t think I had to order any tests.”

    Application of the PERC rule must be confined to a patient population already deemed by the practitioner as low risk. A negative PERC score does not have a negative predictive value high enough to be utilized in any other risk category.

  4. “The D-dimer at triage was negative, so I didn’t think I had to worry about PE.”

    Reliance on D-dimer tests other than the quantitative turbidimetric or ELISA assays is inappropriate. Interrater reliability with the qualitative assays used in many point-of-care assays is inadequate, and the sensitivity of this test is not adequate, particularly in the undifferentiated patient.

  5. “I knew the quantitative D-dimer test is much better than the bedside assays. Since it was negative, I stopped the work-up there.”

    As with the PERC rule, interpretation of a negative D-dimer assay must be done in the context of the clinician’s pretest probability for disease. Current evidence shows that only in patients considered to have a low clinical risk for PE can a negative quantitative D-dimer safely exclude PE.

  6. “The CTPA was negative, so I discharged the patient.”

    As with prior tests mentioned, a negative CTPA (or indeterminate V/Q scan) does not rule out the possibility of PE in a patient considered high risk for emboli. The clinician must interpret the negative results in the context of pretest probability of disease.

  7. “I started the heparin, and his vitals were fine, so I admitted him to the floor.”

    A significant percentage of initially stable patients with pulmonary emboli will deteriorate during their hospital course, requiring escalation of therapy. Evaluation of the patient’s potential for deterioration will aid the clinician in admitting the patient to the correct setting.

  8. “I held the heparin pending the results of his diagnostic tests. I knew he was really tachycardic,

    but I haven’t confirmed the diagnosis yet.”

    In a patient with a high clinical suspicion for disease and signs of hemodynamic instability, initiate anticoagulation therapy immediately. Delayed treatment is associated with increased mortality in these patients.

  9. “I started the patient on 120 mg of enoxaparin. She was dialyzed yesterday.”

    Failure to evaluate for contraindications to specific treatment options can cause significant complications. Patients with renal compromise should be treated with unfractionated heparin. As with all therapeutics, the emergency clinician must have a good understanding of both the indications and contraindications for any therapy initiated.

  10. “I know she was stable, but I thought she would benefit from thrombolytics.”

    Although controversy exists regarding the use of thrombolytic therapy in patients with PE, they are not recommended in stable patients, since the risks outweigh the benefits.

Tables and Figures

Table 1. Venous Thromboembolic Risk Factors



Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. Heit JA, Silverstein MD, Mohr DN, et al. The epidemiology of venous thromboembolism in the community. Arterioscler Thromb Vasc Biol. 2008;28(3):370-372. (Review)
  2. Wood KE. Major pulmonary embolism: Review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest. 2002;121(3):877-905. (Review)
  3. Park B, Messina L, Dargon P, et al. Recent trends in clinical outcomes and resource utilization for pulmonary embolism in the united states: Findings from the nationwide inpatient sample. Chest. 2009;136(4):983-990. (Retrospective national database review; 1,378,670 patients)
  4. Bell WR, Simon TL. Current status of pulmonary thromboembolic disease: Pathophysiology, diagnosis, prevention, and treatment. Am Heart J. 1982;103(2):239-262. (Review)
  5. General S. Acting surgeon general issues “call to action to prevent deep vein thrombosis and pulmonary embolism”. In: Services USDoHH, ed2008.
  6. Cohen AT, Agnelli G, Anderson FA, et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007;98(4):756-764.
  7. Cohen AT, Edmondson RA, Phillips MJ, et al. The changing pattern of venous thromboembolic disease. Haemostasis. 1996;26(2):65-71.
  8. Moser KM. Fatal pulmonary embolism: Old pitfalls, new challenges. Mayo Clin Proc. 1995;70(5):501-502. (Editorial)
  9. Goldhaber SZ. Pulmonary embolism. N Engl J Med. 1998;339(2):93-104. (Review)
  10. Skaf E, Stein PD, Beemath A, et al. Fatal pulmonary embolism and stroke. Am J Cardiol. 2006;97(12):1776-1777. (Retrospective chart review; 11,101 patients)
  11. Aujesky D, Jimenez D, Mor MK, et al. Weekend versus weekday admission and mortality after acute pulmonary embolism. Circulation. 2009;119(7):962-968. (Database analysis; 15,531 patients)
  12. Laporte S, Mismetti P, Decousus H, et al. Clinical predictors for fatal pulmonary embolism in 15,520 patients with venous thromboembolism: findings from the registro informatizado de la enfermedad tromboembolica venosa (riete) registry. Circulation. 2008;117(13):1711-1716. (Registry review; 15,520 patients)
  13. Menzel T, Wagner S, Kramm T, et al. Pathophysiology of impaired right and left ventricular function in chronic embolic pulmonary hypertension: changes after pulmonary thromboendarterectomy. Chest. 2000;118(4):897-903. (Comparative study; 39 patients)
  14. Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism. A statement for healthcare professionals. Council on Thrombosis (in consultation with the Council on Cardiovascular Radiology), American Heart Association. Circulation. 1996;93(12):2212-2245. (Review)
  15. Piazza GS. Chronic thromboembolic pulmonary hypertension. N Engl J Med. 2011;364:351-360. (Review)
  16. Cervantes J, Rojas G. Virchow’s Legacy: deep vein thrombosis and pulmonary embolism. World J Surg 2005;29(Suppl 1):S30-S34. (Historical article)
  17. Dickson BC. Venous thrombosis: On the history of Virchow’s triad. Univ Toronto Med J. 2004;81:166-171. (Historical review)
  18. Kline JA, Mitchell AM, Kabrhel C, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2(8):1247-1255. (Derivation [3148 patients] and validation [1809 patients] of a decision rule)
  19. * Courtney DM, Kline JA, Kabrhel C, et al. Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: Results of a prospective, multicenter study. Ann Emerg Med. 2010;55(4):307-315. (Prospective multicenter study; 7940 patients)
  20. Stein PD, Beemath A, Matta F. Clinical characteristics of patients with acute pulmonary embolism: Data from PIOPED III. Am J Med. 2007;120:871-879. (Prospective multicenter clinical study; 773 patients)
  21. Chunilal SD, Eikelboom JW, Attia J, et al. Does this patient have pulmonary embolism? JAMA. 2003;290(21):2849-2858. (Review)
  22. Kabrhel C, Mark Courtney D, Camargo Jr, et al. Potential impact of adjusting the threshold of the quantitative D-dimer based on pretest probability of acute pulmonary embolism. Acad Emerg Med. 2009;16:325-332. (Prospective multicenter study; 7940 patients)
  23. Sanson BJ, Limer JG, MacGillavry MR, et al. Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group. Thromb Haemost. 2000;83(2):199-203. (Prospective comparative multicenter study; 517 patients)
  24. * Runyon MS, Webb WB, Jones AE, et al. Comparison of the unstructured clinician estimate of pretest probability for pulmonary embolism to the Canadian score and the Charlotte rule: a prospective observational study. Acad Emerg Med. 2005;12(7):587-593. (Prospective; 2603 patients)
  25. The PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism diagnosis. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA. 1990;263:2753-2759. (Prosepective; 1493 patients)
  26. Kabrhel C, Camargo CA Jr, Goldhaber SZ. Clinical gestalt and the diagnosis of pulmonary embolism: does experience matter? Chest. 2005;127(5):1627-1630. (Prospective; 583 patients)
  27. Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: Increasing the models utility with the simplired d-dimer. Thromb Haemost. 2000;83(3):416-420. (Randomized control clinical study)
  28. Klok FA, Mos IC, Nijkeuter M, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Int Med. 2008;168(19):2131-2136. (Prospective; 1049 patients)
  29. Kline JA, Courntney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6(5):722-780.
  30. * Kline JA, Nelson RD, Jackson RE, et al. Criteria for the safe use of D-dimer testing in emergency department patients with suspected pulmonary embolism: A multicenter US study. Ann Emerg Med. 2002;39(2):144-152. (Validation; 934 patients)
  31. Miniati M, Bottai M, Monti S, et al. Simple and accurate prediction of the clinical probability of pulmonary embolism. Am J Respir Crit Care Med. 2008;178(3):290-294. (Validation; 1100 patients)
  32. Lucassen W, Geersing GJ, Erkens PM, et al. Clinical decision rules for excluding pulmonary embolism: A meta-analysis. Ann Intern Med. 2011;155(7):448-460. (Meta-analysis)
  33. Wolf SJ, McCubbin TR, Nordenholz KE, et al. Assessment of the pulmonary embolism rule-out criteria rule for evaluation of suspected pulmonary embolism in the emergency department. Am J Emerg Med. 2008;26(2):181-185. (Validation study; 134 patients)
  34. Drescher FS, Chandrika S, Weir ID, et al. Effectiveness and acceptability of a computerized decision support system using modified Wells criteria for evaluation of suspected pulmonary embolism. Ann Emerg Med. 2011;57(6):613-621. (Prospective; 404 patients)
  35. Goldhaber SZ. Pulmonary embolism. Lancet. 2004;363(9417):1295-1305. (Review)
  36. * Stein PD, Woodard PK, Weg JG, et al. Diagnostic pathways in acute pulmonary embolism: Recommendations of the PIOPED II investigators. Radiology. 2007;242(1):15-21. (Review/guidelines)
  37. Elliott CG, Goldhaber SZ, Visani L, et al. Chest radiographs in acute pulmonary embolism. Results from the International Cooperative Pulmonary Embolism Registry. Chest. 2000;118(1):33-38. (Prospective; 2454 patients)
  38. Stein PD, Terrin ML, Hales CA, et al. Clinical, laboratory, roentgenographic and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest. 1991;100(3):598-603. (Retrospective; 117 patients)
  39. Ferrari E, Imbert A, Chevalier T, et al. The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads - 80 case reports. Chest. 1997;111(3):537-543. (Retrospective; 80 patients)
  40. Kosuge M, Kimura K, Ishikawa T, et al. Prognostic significance of inverted T waves in patients with acute pulmonary embolism. Circ J. 2006;70(6):750-755. (Retrospective; 40 patients)
  41. Kosuge M, Kimura K, Ishikawa T, et al. Electrocardiographic differentiation between acute pulmonary embolism and acute coronary syndromes on the basis of negative T waves. Am J Cardiol. 2007;99(6):817-821. (Retrospective; 127 patients)
  42. Stein PD, Goldhaber SZ, Henry JW, et al. Arterial blood gas analysis in the assessment of suspected acute pulmonary embolism. Chest. 1996;109(1):78-81. (Retrospective; 768 patients)
  43. Stein PD GS, Henry JW. Alveolar-arterial oxygen gradient in the assessment of acute pulmonary embolism. Chest 1995;107(1):139-143. (Retrospective; 280 patients)
  44. Jones JS, Neff TL, Carlson SA. Use of the alveolar-arterial oxygen gradient in the assessment of acute pulmonary embolism. Am J Emerg Med. 1998;16(4):333-337. (Retrospective; 152 patients)
  45. Farrell S, Hayes T, Shaw M. A negative simpliRED D-dimer assay result does not exclude the diagnosis of deep vein thrombosis or pulmonary embolus in emergency department patients. Ann Emerg Med. 2000;35(2):121-125. (Prospective; 173 patients)
  46. * Fesmire FM, Brown MD, Espinosa JA, et al. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011;57(6):628-652. (Guideline)
  47. Brown MD, Rowe BH, Reeves MJ, et al. The accuracy of the enzyme-linked immunosorbent assay D-dimer test in the diagnosis of pulmonary embolism: a meta-analysis. Ann Emerg Med. 2002;40(2):133-144. (Meta-analysis)
  48. Carrier M, Righini M, Djurabi RK, et al. VIDAS D-dimer in combination with clinical pre-test probability to rule out pulmonary embolism. A systematic review of management outcome studies. Thromb Haemost. 2009;101(5):886-892. (Meta-analysis)
  49. Bounameaux H. Contemporary management of pulmonary embolism: the answers to ten questions. J Intern Med. 2010;268(3):218-231. (Review)
  50. Rhigini M, Aujesky D, Roy PM, et al. Clinical usefulness of D-dimer depending on clinical probability and cutoff value in outpatients with suspected pulmonary embolism. Arch Intern Med. 2004;164(22):2483-2487. (Retrospective)
  51. Ouellette DW, Patocka C. Pulmonary embolism. Emerg Med Clin North Am. 2012;30(2):329-375. (Review)
  52. * Stein PD, Fowler SE, Goodman LR, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354(22):2317-2327. (Prospective; 824 patients)
  53. Couturaud F, Parent F, Meyer G, et al. Effect of age on the performance of a diagnostic strategy based on clinical probability, spiral computed tomography and venous compression ultrasonography: The ESSEP study. Thromb Haemost. 2005;93(3):605-609. (Retrospective; 1041 patients)
  54. Remy-Jardin M, Remy J, Wattinne L, et al. Central pulmonary thromboembolism: diagnosis with spiral volumetric CT with the single-breath-hold technique--comparison with pulmonary angiography. Radiology. 1992;185:381-387. (Prospective; 42 patients)
  55. * Carrier M, Righini M, Wells PS, et al. Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. J Thromb Haemost. 2010;8(8):1716-1722. (Systematic review)
  56. Mettler FA, Jr, Huda W, Yoshizumi TT, et al. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology. 2008;248(1):254-263. (Review)
  57. Wang PI, Chong ST, Kielar AZ, et al. Imaging of pregnant and lactating patients: Part 2, evidence-based review and recommendations. AJR Am J Roentgenol. 2012;198(4):785-792. (Review)
  58. No authors listed. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). THE PIOPED Investigators. JAMA. 1990;263(20):2753-2759. (Prospective comparative study; 933 patients)
  59. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23(12):1225-1230. (Consensus development conference)
  60. Goldhaber SZ. Pulmonary embolism thrombolysis: broadening the paradigm for its administration. Circulation. 1997;96(3):716-718. (Editorial)
  61. ten Wolde M, Söhne M, Quak E, et al. Prognostic value of echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism. Arch Intern Med. 2004;164:1685-1689. (Systematic review)
  62. Ribeiro A, Lindmarker P, Juhlin-Dannfelt A, et al. Echocardiography Doppler in pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate. Am Heart J. 1997;134(3):479-487. (Prospective; 141 patients)
  63. Bova C, Greco F, Misuraca G, et al. Diagnostic utility of echocardiography in patients with suspected pulmonary embolism. Am J Emerg Med. 2003;21(3):180-183. (Prospective; 162 patients)
  64. Kasper W, Konstantinides S, Geibel A, et al. Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism. Heart. 1997;77(4):346-349. (Prospective; 317 patients)
  65. Piazza G, Goldhaber SZ. Management of submassive pulmonary embolism. Circulation. 2010;122(11):1124-1129.
  66. Perrier A, Miron MJ, Desmarais S, et al. Using clinical evaluation and lung scan to rule out suspected pulmonary embolism: is it a valid option in patients with normal results of lower-limb venous compression ultrasonography? Arch Intern Med. 2000;160(4):512-516. (Retrospective cohort study; 1034 patients)
  67. Daniel KR, Jackson RE, Kline JA. Utility of lower extremity venous ultrasound scanning in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. 2000;35(6):547-554. (Prospective; 156 patients)
  68. Miniati M, Prediletto R, Formichi B, et al. Accuracy of clinical assessment in the diagnosis of pulmonary embolism. Am J Respir Crit Care Med. 1999;159(3):864-871. (Prospective; 750 patients)
  69. Hull RD, Raskob GE, Ginsberg JS, et al. A noninvasive strategy for the treatment of patients with suspected pulmonary embolism. Arch Intern Med. 1994;154(3):289-297. (Prospective; 1564 patients)
  70. Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129(12):997-1005. (Prospective cohort study; 1239 patients)
  71. Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29(18):2276-2315. (Practice guidelines)
  72. Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolismsimplified pulmonary embolism severity index. Arch Int Med. 2010;170(15):1383-1389. (Prospective; derivation set: 1017 patients; validation set: 7106 patients)
  73. Lankeit M, Gómez V, Wagner C, et al. A strategy combining imaging and laboratory biomarkers in comparison with a simplified clinical score for risk stratification of patients with acute pulmonary embolism. Chest. 2012;141(4):916-922. (Prospective comparative study; 526 patients)
  74. Pruszczyk P, Bochowicz A, Torbicki A, et al. Cardiac troponin T monitoring identifies a high-risk group of normotensive patients with acute pulmonary embolism. Chest. 2003;123(6):1947-1952. (Observational; 64 patients)
  75. Stein PD, Alshabkhoun S, Hatem C, et al. Coronary artery blood flow in acute pulmonary embolism. Am J Cardiol. 1968;21(1):32-37. (Animal study)
  76. Aksay E, Yanturali S, Kiyan S. Can elevated troponin I levels predict complicated clinical course and inhospital mortality in patients with acute pulmonary embolism? Am J Emerg Med. 2007;25(2):138-143. (Retrospective; 77 patients)
  77. Melanson SE, Laposata M, Camargo CA Jr et al. Combination of D-dimer and amino-terminal pro-B-type natriuretic peptide testing for the evaluation of dyspneic patients with and without acute pulmonary embolism. Arch Pathol Lab Med 2006;130(9):1326-1329. (Retrospective; 218 patients)
  78. Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease. Chest. 2001;119(1 Suppl):176S-193S. (Review)
  79. Erkens PM, Prins MH. Fixed-dose subcutaneous low-molecular-weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. Cochrane Database Syst Rev. 2010(9):CD001100. (Meta-analysis; 23 studies)
  80. Agterof MJ, Schutgens RE, Snijder RJ, et al. Out-of-hospital treatment of acute pulmonary embolism in patients with a low NT-proBNP level. J Thromb Haemost. 2010;8(6):1235-1241. (Prospective; 152 patients)
  81. Kucher N, Rossi E, De Rosa M, et al. Massive pulmonary embolism. Circulation. 2006;113(4):577-582. (Retrospective; 2392 patients)
  82. No authors listed. Urokinase pulmonary embolism trial. Phase 1 results: a cooperative study. JAMA. 1970;214(12):2163-2172. (Prospective; 11 patients)
  83. No authors listed. The urokinase pulmonary embolism trial. A national cooperative study. Circulation. 1973;47(2 Suppl):II1-108.
  84. Verstraete M, Miller GA, Bounameaux H, et al. Intravenous and intrapulmonary recombinant tissue-type plasminogen activator in the treatment of acute massive pulmonary embolism. Circulation. 1988;77(2):353-360. (Randomized controlled trial; 34 patients)
  85. Goldhaber SZ. TPA versus urokinase in acute pulmonary embolism: results of a randomized controlled trial. Vasa Suppl. 1989;27:292-294. (Randomized controlled trial; 45 patients)
  86. Goldhaber SZ. Tissue plasminogen activator in acute pulmonary embolism. Chest. 1989;95(5 Suppl):282S-289S. (Review)
  87. Meyer G, Sors H, Charbonnier B, et al. Effects of intravenous urokinase versus alteplase on total pulmonary resistance in acute massive pulmonary embolism: a European multicenter double-blind trial. Journal of the American College of Cardiology. 1992;19(2):239-245. (Randomized controlled trial; 63 patients)
  88. Goldhaber SZ, Haire WD, Feldstein ML, et al. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion. Lancet. 1993;341(8844):507-511. (Randomized controlled trial; 46 patients)
  89. Konstantinides S, Geibel A, Heusel G, et al. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med. 2002;347(15):1143-1150. (Randomized controlled trial; 256 patients)
  90. Stein PD, Matta F. Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. Am J Med. 2012;125(5):465-470. (Retrospective national database review; 72,230 patients)
  91. National Guidelines Clearinghouse. ACR Appropriateness Criteria® radiologic management of inferior vena cava filters. Available at: Accessed May 31, 2012. (Guideline)
  92. Kearon C, Kahn SR, Agnelli G, et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6 Suppl):454S-545S. (Practice guideline)
  93. Burge AJ, Freeman KD, Klapper PJ, et al. Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era. Clin Radiol. 2008;63(4):381-386. (Retrospective statewide database review)
  94. Sheh SH, Bellin E, Freeman KD, et al. Pulmonary embolism diagnosis and mortality with pulmonary CT angiography versus ventilation-perfusion scintigraphy: evidence of overdiagnosis with CT? AJR Am J Roentgenol. 2012;198(6):1340-1345. (Retrospective; 2087 patients)
  95. Stein EG, Haramati LB, Chamarthy M, et al. Success of a safe and simple algorithm to reduce use of CT pulmonary angiography in the emergency department. AJR Am J Roentgenol. 2010;194(2):392-397. (Prospective)
  96. Anderson DR, Kahn SR, Rodger MA, et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolisma randomized controlled trial. JAMA. 2007;298(23):2743-2753. (Prospective randomized controlled trial; 1417 patients)
  97. Remy-Jardin M, Pistolesi M, Goodman LR, et al. Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology. 2007;245(2):315-329. (Review)
  98. Leung AN, Bull TM, Jaeschke R, et al. An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy. Am J Respir Crit Care Med. 2011;184(10):1200-1208. (Guidelines)




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Amy Church; Matthew Tichauer

Publication Date

December 2, 2012

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