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  • Review Article
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Acute pulmonary embolism. Part 1: epidemiology and diagnosis

Nature Reviews Cardiology volume 7, pages 585–596 (2010)Cite this article

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Abstract

Pulmonary embolism (PE) is a frequently occurring, acute, and potentially fatal condition. Numerous risk factors for PE, both inherited and acquired, have been identified. Adequate diagnosis is mandatory to prevent PE-related morbidity and mortality on the one hand, and unnecessary treatment on the other. Only around 1 in 5 individuals with suspected PE will have the diagnosis confirmed, therefore, the diagnostic work-up for PE should comprise safe, efficient, and noninvasive methods. The first step in the approach to diagnosis of patients with suspected PE is to determine the clinical probability and to perform a D-dimer test. PE can be excluded in patients with a 'low', 'intermediate' or 'unlikely' clinical probability and a normal D-dimer test. Additional imaging is required for those with a 'high' or 'likely' clinical probability or a positive D-dimer test. CT pulmonary angiography or ventilation–perfusion scintigraphy, followed by additional testing is the next step when test results are nondiagnostic. Although various diagnostic strategies have been introduced and validated, selected patients may require a tailored approach.

Key Points

  • Venous thromboembolism, and more specifically pulmonary embolism, is a frequently occurring and potentially fatal condition for which improved diagnosis and treatment are necessary

  • Both inherited and acquired risk factors for pulmonary embolism have been identified, including thrombophilia, surgery, cancer, immobilization, and previous venous thromboembolism

  • The clinical diagnosis of pulmonary embolism can be difficult because of variation in signs and symptoms; for accurate diagnosis, several diagnostic tests should be incorporated in an integrated approach

  • Fewer than 20% of patients with suspected pulmonary embolism actually have the condition; the main initial challenge is to adequately exclude a diagnosis of PE

  • The first diagnostic step is to assess the clinical probability of pulmonary embolism using a standardized score, followed by D-dimer testing and, if necessary, multidetector CT pulmonary angiography or ventilation–perfusion scanning

  • The diagnostic strategy and the choice of imaging test depend on the clinical status of the patient and the availability of diagnostic tools

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Figure 1: Pathophysiology of pulmonary embolism.
Figure 2: Annual incidence of venous thromboembolism (pulmonary embolism and deep-vein thrombosis combined) among residents of Worcester, MA, USA in 1986 by age and sex.
Figure 3: Diagnostic approach to suspected acute pulmonary embolism.
Figure 4

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Authors and Affiliations

  1. Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105, AZ, The Netherlands

    Renée A. Douma, Pieter W. Kamphuisen & Harry R. Büller

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  1. Renée A. Douma
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  2. Pieter W. Kamphuisen
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Contributions

R. A. Douma and P. W. Kamphuisen researched data for the article. R. A. Douma, P. W. Kamphuisen and H. R. Büller contributed to discussion of content for the article. R. A. Douma wrote the article and revised it in response to the peer-reviewers' comments. P. W. Kamphuisen and H. R. Büller reviewed and edited the manuscript before submission.

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Correspondence to Renée A. Douma.

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Douma, R., Kamphuisen, P. & Büller, H. Acute pulmonary embolism. Part 1: epidemiology and diagnosis. Nat Rev Cardiol 7, 585–596 (2010). https://doi.org/10.1038/nrcardio.2010.106

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