Thorax 69:174-180 doi:10.1136/thoraxjnl-2013-204667
  • Review

Management dilemmas in acute pulmonary embolism

Open Access
  1. David G Kiely1,2
  1. 1Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
  2. 2Academic Department of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
  3. 3Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
  4. 4Department of Infection and Immunology, University of Sheffield, Sheffield, UK
  1. Correspondence to Dr Robin Condliffe, Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK; robin.condliffe{at}
  • Received 10 October 2013
  • Revised 22 November 2013
  • Accepted 27 November 2013
  • Published Online First 16 December 2013


Background Physicians treating acute pulmonary embolism (PE) are faced with difficult management decisions while specific guidance from recent guidelines may be absent.

Methods Fourteen clinical dilemmas were identified by physicians and haematologists with specific interests in acute and chronic PE. Current evidence was reviewed and a practical approach suggested.

Results Management dilemmas discussed include: sub-massive PE, PE following recent stroke or surgery, thrombolysis dosing and use in cardiac arrest, surgical or catheter-based therapy, failure to respond to initial thrombolysis, PE in pregnancy, right atrial thrombus, role of caval filter insertion, incidental and sub-segmental PE, differentiating acute from chronic PE, early discharge and novel oral anticoagulants.

Conclusion The suggested approaches are based on a review of the available evidence and guidelines and on our clinical experience. Management in an individual patient requires clinical assessment of risks and benefits and also depends on local availability of therapeutic interventions.

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