The presenting signs and symptoms of pulmonary embolism are non-specific and a high degree of clinical suspicion is needed to make the diagnosis. Presence of a risk factor for VTE should make one think of this diagnosis, in the appropriate setting. Diagnostic algorithms incorporating D-dimer testing have been validated to investigate suspected PE. CT pulmonary angiography (CTPA) is the imaging modality of choice, which should be performed only after appropriate evaluation and risk-stratification. For PE associated with persistent shock, thrombolysis is considered appropriate, whereas anticoagulation is indicated for patients with smaller PE, including sub-massive/intermediate risk PE. A subset of patients with low risk PE, as stratified by scores such as the PESI or sPESI, are appropriate for out-patient care. Those with unprovoked VTE are at increased risk of recurrence. The individual risk of recurrence needs to be considered against the bleeding risk with long term anticoagulation. Direct oral anticoagulants are as effective as warfarin and have a lower risk of bleeding events, and effective reversal agents are becoming available.
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