This document defines massive, submassive, and low-risk pulmonary embolism (PE) and provides diagnostic criteria for each. Massive PE is defined by sustained hypotension, pulselessness, or profound bradycardia. Submassive PE is defined by right ventricular dysfunction or myocardial necrosis without hypotension. Low-risk PE lacks the criteria for massive or submassive PE. Diagnostic tests and initial treatment recommendations are also summarized.

1. PULMONARY EMBOLISM

2. Definition for Massive PE
Acute PE with with at least 1 of the following:
1. Sustained hypotension
SBP <90 mmHg for at least 15 minutes or
requiring inotropic support, not due to a cause
other than PE, such as arrhythmia, hypovolemia,
sepsis, or LV dysfunction
2. Pulselessness
3. Persistent profound bradycardia
heart rate <40 bpm with signs or symptoms of
shock

3. Definition for Submassive PE
Acute PE without systemic hypotension (SBP >90 mm Hg)
but with either RV dysfunction or myocardial necrosis.
• RV dysfunction means the presence of at least 1 of the
following:
– Echo: RV dilation (apical 4-chamber RV diameter divided by LV
diameter >0.9), or RV systolic dysfunction
– CT: RV dilation (4-chamber RV diameter divided by LV diameter > 0.9)
– BNP > 90 pg/mL or N-terminal pro-BNP > 500 pg/mL
– ECG changes: New complete or incomplete RBBB, anteroseptal ST
elevation or depression, or anteroseptal T-wave inversion
• Myocardial necrosis is defined as either of the following:
– Troponin I > 0.4 ng/mL, or Troponin T > 0.1 ng/mL

4. Definition for Low-Risk PE
Acute PE and the absence of the clinical markers
of adverse prognosis that define massive or
submassive PE.

8. PERC
June 3, 2018 8
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;2:1247–55.

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11. PESI
to differentiate
Int from Low
Risk
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12. Pulmonary Embolism Severity Index (PESI)
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17. LAB
• Troponin ‐ released from right ventricle Injury
• Cardiac BNP ‐ released from cardiac myocytes in response to elevated pressures 
RVD
*A normal troponin and BNP can safely exclude high risk patients with a negative
predictive value of 97-100%
• H-FABP (heart type fatty acid binding protein) – early marker for injury (good for
prognosis as well)
• NGAL (neutrophil gelatinase associated lipocalin) & Cystatin C – both indicating
kidney injury, also shown to have prognostic value
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18. D-dimer
• patients with PE have ongoing endogenous fibrinolysis that is not
effective enough to prevent PE but that does break down fibrin clot
to d-dimers .
• they are not specific.
• negative d-dimer results, additional diagnostic testing not
necessary
• PE in low-risk patients with a negative D-dimer…
– Thrombus formation >72 hrs before blood draw (circulating dimer t1/2
= 8 hrs)
– Subsegmental PE
• False-positives = age >70, pregnancy, active malignancy, recent
surgery, liver disease, RA, infections, trauma
• False-negatives = Coumadin use, symptoms >5days, small clots or
infarction, isolated calf vein thrombosis.

21. • Westermark sign - focal oligemia

22. Hampton hump –Wedge shaped density above
diaphragm- indicates pul. infarction

23. Pallas sign – enlargement of descending
R pulmonary artery

26. Ventilation Perfusion Scan
Indications:
- Renal failure
- Pregnancy
Procedure:
- Ventilation scan with Xenon inhalation
- Perfusion scan with Tc99m labelled radioactive dye infusion
- Scan V/Q
- Result: unmatched V/Q
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29. Indications:
- Suspected PE
Contra-indications:
- Renal failure
- Pregnancy
- Allergy to radio-contrast
1.7-5% risk of developing breast cancers (Hurwitz et al. 2007)
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CT-PA

32. Multidetector helical CT-PA
• First line modality
• Cover all chest with high spatial resolution in one breath
• Detect peripheral smaller emboli
• Detect other pathologies
• Detect RV strain (straightening or leftward bowing of IV septum)
• Radiation Exposure
• # in renal failure and contrast allergy
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36. • Heparin passive reduction of thrombus size.
• Thrombolytic agents actively promote the
hydrolysis of fibrin molecules.
• At 24 hours, patients treated with heparin have
no substantial improvement in pulmonary blood
flow, whereas patients treated with adjunctive
fibrinolysis manifest a 30% to 35% reduction in
total perfusion defect. However, by 7 days, blood
flow improves similarly (65% to 70% reduction in
total defect).

37. Recommendations for Initial
Anticoagulation for Acute PE
1. Therapeutic anticoagulation with subcutaneous
LMWH, intravenous or subcutaneous UFH with
monitoring, unmonitored weight-based
subcutaneous UFH, or subcutaneous
fondaparinux should be given to patients with
objectively confirmed PE and no
contraindications to anticoagulation (Class I;
Level of Evidence A).
2. Therapeutic anticoagulation during the
diagnostic workup should be given to patients
with intermediate or high clinical probability of
PE and no contraindications to anticoagulation
(Class I; Level of Evidence C).

39. Recommendations for Fibrinolysis for
Acute PE
1. Fibrinolysis is reasonable for patients with massive acute PE and
acceptable risk of bleeding complications (Class IIa; Level of
Evidence B).
2. Fibrinolysis may be considered for patients with submassive acute
PE judged to have clinical evidence of adverse prognosis (new
hemodynamic instability, worsening respiratory insufficiency,
severe RV dysfunction, or major myocardial necrosis) and low
risk of bleeding complications (Class IIb; Level of Evidence C).
3. Fibrinolysis is not recommended for patients with low-risk PE
(Class III; Level of Evidence B) or submassive acute PE with minor
RV dysfunction, minor myocardial necrosis, and no clinical
worsening (Class III; Level of Evidence B).
4. Fibrinolysis is not recommended for undifferentiated cardiac
arrest (Class III; Level of Evidence B).

40. Pharmacological Profile of Plasminogen-
Activating Fibrinolytic Agents
Fibrinolytic
FDA Indication
for PE?
Fibrinolytic Dose
Streptokinase Yes
250 000-IU IV bolus followed by
100 000-IU/h infusion for 12–24 h
Urokinase Yes
4400-IU/kg bolus, followed by 4400
IU．kg－1．h－1 for 12–24 h
Alteplase Yes 100-mg IV infusion over 2 h
Reteplase No Double 10-U IV bolus 30 min apart
Tenecteplase No
Weight-adjusted IV bolus over 5 s
(30–50 mg with a 5-mg step every
10 kg from <60 to >90 kg)

41. Recommendations on IVC Filters in
the Setting of Acute PE
1. Adult patients with any confirmed acute PE (or proximal
DVT) with contraindications to anticoagulation or with
active bleeding complication should receive an IVC filter
(Class I; Level of Evidence C).
2. Anticoagulation should be resumed in patients with an
IVC filter once contraindications to anticoagulation or
active bleeding complications have resolved (Class I; Level
of Evidence B).
3. Patients who receive retrievable IVC filters should be
evaluated periodically for filter retrieval within the specific
filter’s retrieval window (Class I; Level of Evidence C).
4. For patients with recurrent acute PE despite therapeutic
anticoagulation, it is reasonable to place an IVC filter
(Class IIa; Level of Evidence C).

42. Recommendations on IVC Filters in
the Setting of Acute PE
5. For DVT or PE patients who will require permanent IVC filtration (eg,
those with a long-term contraindication to anticoagulation), it is
reasonable to select a permanent IVC filter device (Class IIa; Level of
Evidence C).
6. For DVT or PE patients with a time-limited indication for an IVC filter
(eg, those with a short-term contraindication to anticoagulation
therapy), it is reasonable to select a retrievable IVC filter device
(Class IIa; Level of Evidence C).
7. Placement of an IVC filter may be considered for patients with acute
PE and very poor cardiopulmonary reserve, including those with
massive PE (Class IIb; Level of Evidence C).
8. An IVC filter should not be used routinely as an adjuvant to
anticoagulation and systemic fibrinolysis in the treatment of acute
PE (Class III; Level of Evidence C).