[Diagnosis and treatment of pulmonary embolism]

Pulmonary embolism (PE) is a common disease that poses a major diagnostic challenge because symptoms and signs are neither sensitive nor specific. However, patients with suspected PE can be classified into low, moderate and high clinical probability groups on the basis of symptoms and signs of PE, the presence of risk factors and the presence or absence of a likely alternative diagnosis. Stratification of patients into groups according to the clinical or pretest probability is imperative for proper selection of further diagnostic tests. The role of D-dimer testing is limited to the ruling out of PE in patients with low or moderate clinical probability. Conversely D-dimer testing is useless in patients, with high clinical probability. Chest CT has become an attractive means for an accurate diagnosis of PE and may replace lung scanning as first-line imaging test in particular in patients with underlying pulmonary disease or abnormal chest radiograph. Initial treatment for patients with non massive PE consists of therapeutic anti-coagulation with low molecular weight heparin (LMWH) and early overlapping with oral anticoagulants. In patients with active cancer, long-term treatment with LMWH is recommended. Duration of anticoagulant treatment is based on the balance between the risk of recurrent venous thromboembolism (depending mainly on the reversibility of risk factor, the presence of cancer, thrombophilia or previous venous thromboembolic episodes) and the risk of bleeding.