title: Advances in the diagnosis and management of acute pulmonary embolism.
abstract: The diagnostic management of acute pulmonary embolism (PE) is complicated by its heterogeneous clinical presentation. Current diagnostic algorithms, combining clinical probability estimation with D-dimer testing and imaging tests, are very safe to exclude PE, although at costs of high numbers of CT-examinations. In view of cost- and time-saving as well as safety issues, several attempts have recently been undertaken to reduce the number of required imaging tests. Especially the age-adjusted D-dimer threshold has greatly improved the potential for non-invasive exclusion of PE. Once the diagnosis of PE is established, immediate initiation of anticoagulant therapy is of vital importance. A new generation of direct oral anticoagulants, which overcomes the main disadvantages of conventional vitamin-K antagonists, has recently emerged. Risk stratification of hemodynamically stable PE patients with use of clinical decision rules, cardiac biomarkers or imaging tests, aids physicians in determining the most appropriate treatment approach for the individual patient. This is essential to differentiate patients at low risk of adverse outcome, who may be safely treated at home, from intermediate-risk patients, who require closer monitoring and for whom recent studies have evaluated the efficacy and safety of systemic thrombolytic therapy. This article reviews recent advances and challenges that remain in the diagnostic work-up and initial management of acute, clinically stable PE.
authors.affiliation: Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands. Electronic address: p.l.den_exter@lumc.nl.
authors.forename: Paul L
authors.initials: PL
authors.lastname: den Exter
authors.affiliation: Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Tom
authors.initials: T
authors.lastname: van der Hulle
authors.affiliation: Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Frederikus A
authors.initials: FA
authors.lastname: Klok
authors.affiliation: Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Menno V
authors.initials: MV
authors.lastname: Huisman
mesh_terms: D000208:Acute Disease; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects*; D006470:Hemorrhage / Q000139:chemically induced* / Q000453:epidemiology; D006801:Humans; D011655:Pulmonary Embolism / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology; D018570:Risk Assessment; D012307:Risk Factors
chemical_list: D000925:Anticoagulants
keywords: Computed-tomography pulmonary; D-dimer; Diagnosis; Management; Pulmonary embolism; Risk stratification; angiography