Pulmonary Embolism: A Clinician's Perspective

Recent advances in the management of patients with suspected pulmonary embolism (PE) have both improved diagnostic accuracy as well as made management algorithms safer and more accessible. Physicians need to more frequently consider PE in patients with chest pain or dyspnea and should be aware of the proper diagnostic approach. Diagnostic strategies should include pretest clinical probability, D-dimer assays, and imaging tests. Although it has been proven that the use of algorithms result in better outcomes, there are patient-specific issues that must be considered. Approaches that use computed tomographic pulmonary angiography or ventilation-perfusion (V/Q) scanning appear equally safe, but each approach has advantages and disadvantages that should be appreciated to provide the best care. Ongoing clinical trials are evaluating whether these diagnostic processes can be made even easier and less expensive. Importantly, patients at low risk with a negative D-dimer can avoid imaging tests and those at moderate risk with a negative high sensitivity D-dimer can have venous thromboembolism excluded without the need for imaging. However, these patients also represent those most likely to have false-positive tests and clinically irrelevant PE. V/Q scanning may be more appropriate in premenopausal women, in those with renal dysfunction or diabetes, in those with known contrast allergies, and perhaps in patients with known family history of breast cancer. As with any illness, there is room for improvement in the management of PE, but it remains unknown whether preventive measures, diagnosis, treatment modalities, or physician or patient education should be the focus.