Cardiopulmonary
Acute pulmonary embolism: risk stratification and treatment
How to estimate probability, choose testing, stratify severity, and decide between anticoagulation and reperfusion.
10 min read·advanced·
Reviewed by a licensed nurse · 2 November 2026
Severity classes
| Class | Hemodynamics | RV strain or troponin | Typical management |
|---|---|---|---|
| High risk (massive) | Sustained hypotension or shock | Present | Systemic thrombolysis, or catheter or surgical embolectomy if contraindicated |
| Intermediate-high | Stable | Both RV dysfunction and raised troponin | Anticoagulation with close monitoring, rescue reperfusion if deterioration |
| Intermediate-low | Stable | One or neither | Anticoagulation, admission |
| Low risk | Stable | Absent, low PESI score | Anticoagulation, consider early discharge |
Approach to suspected embolism
- 01
Stabilize
Oxygen, intravenous access, and hemodynamic support. Avoid large fluid volumes in right ventricular failure.
- 02
Estimate probability
Wells or revised Geneva score. Use PERC only in low-risk patients.
- 03
Test
D-dimer when probability is low or intermediate. CT pulmonary angiography when probability is high or D-dimer is positive.
- 04
Anticoagulate
Begin low-molecular-weight heparin, fondaparinux, or a direct oral anticoagulant while confirming, if the risk of bleeding allows.
- 05
Stratify
Blood pressure, echocardiogram or CT for RV strain, troponin, and a PESI or sPESI score.
Contraindications to thrombolysis
- ·Prior intracranial hemorrhage.
- ·Ischemic stroke in the past 3 months.
- ·Active bleeding or major trauma or surgery in recent weeks.
- ·Intracranial tumor or vascular lesion.
- ·These are weighed against the risk of death in a high-risk embolism.
Duration of anticoagulation
- ·At least 3 months for all patients.
- ·Provoked by a major transient factor: stop at 3 months.
- ·Unprovoked: consider extended therapy based on bleeding risk.
- ·Cancer-associated: continue while the cancer is active.
- ·Pregnancy: low-molecular-weight heparin, since warfarin and direct oral anticoagulants are avoided.
Check yourself
Did it stick?
1. A patient with a low pretest probability for pulmonary embolism has a negative D-dimer. What is the next step?
2. A patient with confirmed pulmonary embolism has a blood pressure of 78/50 mmHg and no contraindications. What is the best treatment?
3. Which anticoagulation approach is appropriate in pregnancy with pulmonary embolism?
Sources
More in AGACNP certification
Educational content for exam preparation. It is not clinical guidance and does not replace your facility's policies, current professional guidelines or the advice of a qualified clinician.