Pulmonary embolism guidelines diagnosis

Associate Editors-in-Chief: Ujjwal Rastogi, MBBS [mailto:urastogi@perfuse.org]

ESC Guidelines for Suspected high-risk PE (DO NOT EDIT)
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Class I
1. In high-risk PE, as indicated by the presence of shock or hypotension, emergency CT or bedside echocardiography (depending on availability and clinical circumstances) is recommended for diagnostic purposes. (Level of Evidence: C)}}

ESC Guidelines for Suspected non-high-risk PE (DO NOT EDIT)
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Class I
1. In non-high-risk PE, basing the diagnostic strategy on clinical probability assessed either implicitly or using a validated prediction rule is recommended. (Level of Evidence: A)

2. Plasma D-dimer measurement is recommended in emergency department patients to reduce the need for unnecessary imaging and irradiation, preferably using a highly sensitive assay. (Level of Evidence: A)

Class IIb
3. Lower limb compression venous ultrasonography (CUS) in search of DVT may be considered in selected patients with suspected PE to obviate the need for further imaging tests if the result is positive. (Level of Evidence: B)

Class III
4. Systematic use of echocardiography for diagnosis in haemodynamically stable, normotensive patients is not recommended. (Level of Evidence: C)

Class IIa
5. Pulmonary angiography should be considered when there is discrepancy between clinical evaluation and results of non-invasive imaging tests. (Level of Evidence: C)

Class I
6. The use of validated criteria for diagnosing PE is recommended. Validated criteria according to clinical probability of PE (low, intermediate or high) are detailed below. (Level of Evidence: B) }}

Low clinical probability
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Class I
1. Normal D-dimer level using either a highly or moderately sensitive assay excludes PE. (Level of Evidence: A)

2. Normal perfusion lung scintigraphy excludes PE. (Level of Evidence: A)

Class IIa
3. Non-diagnostic (low or intermediate probability) V/Q scan may exclude PE, (Level of Evidence: B) particularly when combined with negative proximal CUS (Class I,Level of Evidence: A)

Class I
4. Negative Multi-slice Detector CT (MDCT) safely excludes PE. (Level of Evidence: A)

Class I
5. Negative Single-slice Detector CT (SDCT) only excludes PE when combined with negative proximal compression venous ultrasonography. (Level of Evidence: A)

Class IIb
6. High-probability V/Q scan may confirm PE but further testing may be considered in selected patients to confirm PE. (Level of Evidence: B)

Class I
7. Compression venous ultrasonography (CUS) showing a proximal DVT confirms PE. (Level of Evidence: B)

Class IIa
8. If Compression venous ultrasonography shows only a distal DVT, further testing should be considered to confirm PE. (Level of Evidence: B)

Class I
9. SDCT or MDCT showing a segmental or more proximal thrombus confirms PE. (Level of Evidence: A)

Class IIa
10. Further testing should be considered to confirm PE if SDCT or MDCT shows only subsegmental clots. (Level of Evidence: B)

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Intermediate clinical probability
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Class I
1. Normal D-dimer level using a highly sensitive assay excludes PE. (Level of Evidence: A)

Class IIa
2. Further testing should be considered if D-dimer level is normal when using a less sensitive assay. (Level of Evidence: B)

Class I
3. Normal perfusion lung scintigraphy excludes PE. (Level of Evidence: A)

Class I
4. In case of a non-diagnostic V/Q scan, further testing is recommended to exclude or confirm PE. (Level of Evidence: B)

Class I
5. Negative MDCT excludes PE. (Level of Evidence: A)

6. Negative SDCT only excludes PE when combined with negative proximal CUS.(Level of Evidence: A)

7. High-probability ventilation–perfusion lung scintigraphy confirms PE. (Level of Evidence: A)

8. Compression venous ultrasonography showing a proximal DVT confirms PE. (Level of Evidence: B)

Class IIa
9. If compression venous ultrasonography shows only a distal DVT, further testing should be considered. (Level of Evidence: B)

Class I
10. SDCT or MDCT showing a segmental or more proximal thrombus confirms PE. (Level of Evidence: A)

Class IIb
11. Further testing may be considered in case of subsegmental clots to confirm PE. (Level of Evidence: B) }}

High clinical probability
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Class III
1. D-dimer measurement is not recommended in high clinical probability patients as a normal result does not safely exclude PE even when using a highly sensitive assay. (Level of Evidence: C)

Class IIa
2. In patients with a negative CT, further tests should be considered in selected patients to exclude PE. (Level of Evidence: B)

Class I
3. High-probability ventilation–perfusion lung scintigraphy confirms PE. (Level of Evidence: A)

Class I
4. Compression venous ultrasonography showing a proximal DVT confirms PE. (Level of Evidence: B)

Class IIb
5. If compression venous ultrasonography shows only a distal DVT, further testing should be considered. (Level of Evidence: B)

Class I
6. SDCT or MDCT showing a segmental or more proximal thrombus confirms PE.(Level of Evidence: A)

Class IIb
7. Further testing may be considered where there are subsegmental clots, to confirm PE. (Level of Evidence: B)

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Guidelines Resources

 * Guidelines on the diagnosis and management of acute pulmonary embolism.