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Clinical Review State of the Art Review

Pulmonary embolism: update on management and controversies

BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2177 (Published 05 August 2020) Cite this as: BMJ 2020;370:m2177
  1. Lisa Duffett, associate scientist, assistant professor12,
  2. Lana A Castellucci, scientist, assistant professor12,
  3. Melissa A Forgie, vice dean of undergraduate medical education and professor of medicine2
  1. 1Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
  2. 2Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
  1. Correspondence to: L A Castellucci lcastellucci{at}toh.ca

ABSTRACT

Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. The diagnosis, risk assessment, and management of pulmonary embolism have evolved with a better understanding of efficient use of diagnostic and therapeutic options. The use of either clinical probability adjusted or age adjusted D-dimer interpretation has led to a reduction in diagnostic imaging to exclude pulmonary embolism. Direct oral anticoagulation therapies are safe, effective, and convenient treatments for most patients with acute venous thromboembolism, with a lower risk of bleeding than vitamin K antagonists. These oral therapeutic options have opened up opportunities for safe outpatient management of pulmonary embolism in selected patients. Recent clinical trials exploring the use of systemic thrombolysis in intermediate to high risk pulmonary embolism suggest that this therapy should be reserved for patients with evidence of hemodynamic compromise. The role of low dose systemic or catheter directed thrombolysis in other patient subgroups is uncertain. After a diagnosis of pulmonary embolism, all patients should be assessed for risk of recurrent venous thromboembolism to guide duration of anticoagulation. Patients with a venous thromboembolism associated with a strong, transient, provoking risk factor can safely discontinue anticoagulation after three months of treatment. Patients with an ongoing strong risk factor, such as cancer, or unprovoked events are at increased risk of recurrent events and should be considered for extended treatment. The use of a risk prediction score can help to identify patients with unprovoked venous thromboembolism who can benefit from extended duration therapy. Despite major advances in the management of pulmonary embolism, up to half of patients report chronic functional limitations. Such patients should be screened for chronic thromboembolic pulmonary hypertension, but only a small proportion will have this as the explanation of their symptoms. In the remaining patients, future studies are needed to understand the pathophysiology and explore interventions to improve quality of life.

Footnotes

  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: LD and LAC did the primary literature search in collaboration with a health information librarian. LD was the lead author of the manuscript, and LAC wrote the sections on choice of anticoagulation for acute pulmonary embolism, treatment of cancer associated pulmonary embolism, and duration of treatment for pulmonary embolism. MAF guided the writing of the full manuscript. All authors reviewed the full manuscript and contributed to its content and references.

  • Funding: LAC is supported by Heart and Stroke Foundation of Canada National New Investigator and Ontario Clinician Scientist Phase I award. LD, LAC, and MAF are investigators of the Canadian Venous Thromboembolism Clinical Trials and Outcomes Research (CanVECTOR) Network; the Network receives grant funding from the Canadian Institutes of Health Research (Funding Reference: CDT-142654). CanVECTOR’s Patient Partners platform provided support for patient engagement activities..

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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