[Diagnosis and treatment of acute pulmonary embolism]

Only in one fourth to one third of patients admitted for suspected acute pulmonary embolism (PE) is PE objectively confirmed, implying that symptoms and clinical findings of acute PE are nonspecific. Clinical pretest probability for PE may be estimated on the basis of validated clinical scores. A low clinical pretest probability and a negative D-dimer value allow exclusion of PE without further imaging procedure. Among imaging techniques, multislice CT scanning has become the preferred method to visualize PE. Alternatively, a combination of clinical pretest probability, D-dimer value and a perfusion/ventilation scan may be performed. The majority of patients presenting with acute segmental or subsegmental PE are hemodynamically stable. Right ventricular function may, however, be disturbed, and an echocardiography should be performed, therefore. Anticoagulation initiated with unfractionated or low-molecular-weight heparins or with the pentasaccharide fondaparinux overlapping with oral anticoagulation using vitamin K antagonists is the standard therapy for hemodynamically stable patients without major right ventricular dysfunction. A transthoracic echocardiography should be performed without delay in patients with suspected central PE and a positive shock index of > or = 1.0 to determine right ventricular function. When major right ventricular dysfunction is found due to central massive PE, immediate performance of surgical or catheter-guided embolectomy or thrombolysis should be considered.