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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Pulmonary embolism

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Suspected PE with shock, persistent hypotension, syncope with hypoperfusion, severe hypoxaemia or cardiac arrest needs immediate resuscitation, senior/critical-care help and urgent reperfusion assessment; do not transport an unstable patient to imaging without a safety plan.

Synopsis

Use the NICE Wells/D-dimer/CTPA pathway, start timely anticoagulation, identify haemodynamic instability and decide duration and follow-up safely.

  • PE ranges from incidental segmental clot to obstructive shock; haemodynamic instability overrides routine outpatient diagnostic sequencing.
  • If overall clinical suspicion is low and another diagnosis is feasible, consider the PERC rule to decide whether further PE testing is needed.
  • Use the 2-level PE Wells score: more than 4 means PE likely and prompts immediate CTPA; 4 or less means PE unlikely and prompts D-dimer first.
  • If CTPA or D-dimer cannot be obtained within the NICE timeframe, give interim therapeutic anticoagulation unless contraindicated after baseline bloods; do not wait for lab results to start it.
  • For confirmed stable PE, NICE first-line options are apixaban or rivaroxaban when suitable; renal impairment, active cancer, antiphospholipid syndrome, extreme body weight, pregnancy and interactions may change the choice.
  • For PE with haemodynamic instability, use continuous UFH and consider systemic thrombolysis; do not routinely thrombolyse a haemodynamically stable PE even when RV dysfunction is present.
  • Treat confirmed PE for at least 3 months; at 3 months reassess provoking factor, recurrence risk, bleeding risk and preference before stopping or extending.
  • In PE-related cardiac arrest, RCUK 2025 supports fibrinolysis, surgical embolectomy or percutaneous thrombectomy for known PE and considering 60–90 minutes of CPR after thrombolysis in selected suspected cases.

    • Key red flags

    High-risk PE

    Cardiac arrest, persistent hypotension, shock, altered mentation, cool peripheries or rising lactate indicates obstructive RV failure and needs immediate reperfusion assessment.

    Investigation priorities

    01
    Clinical probability: PERC when suspicion is low, then 2-level PE WellsFirst step

    Select who needs no test, D-dimer or immediate imaging.

    Management branches

    First-lineStable suspected PE

    PE suspected without haemodynamic instability

    1. If clinical suspicion is low and another diagnosis is feasible, consider PERC; otherwise calculate the 2-level PE Wells score.
    2. If Wells >4, arrange immediate CTPA; if imaging is delayed, give interim therapeutic anticoagulation after baseline bloods unless contraindicated.
    3. If Wells ≤4, obtain D-dimer; if the result is delayed beyond the NICE timeframe, give interim anticoagulation, and image if positive.
    4. If PE is excluded, stop interim anticoagulation and pursue an alternative diagnosis; give clear safety-net advice.
    Second-lineConfirmed stable PE

    Imaging-confirmed PE without shock

    1. Assess bleeding, renal/liver function, cancer, pregnancy potential, antiphospholipid syndrome, weight, interactions and suitability for outpatient care.
    2. Offer apixaban or rivaroxaban when suitable; use LMWH followed by dabigatran/edoxaban, or LMWH plus VKA, when the first-line DOACs are unsuitable according to NICE.
    3. Treat for at least 3 months and provide an anticoagulant alert, bleeding/missed-dose advice and written review date.

    Key medicines

    Apixaban10 mg orally twice daily for 7 days, then 5 mg twice daily. If extended prevention is indicated after 6 months of treatment, 2.5 mg twice daily is the licensed recurrence-prevention dose.Active bleeding, strong dual CYP3A4/P-gp interactions and hepatic coagulopathy. For VTE, use caution when creatinine clearance is 15–29 mL/min and do not use below 15 mL/min or on dialysis; do not apply the AF age/weight/creatinine dose-reduction rule.
    Rivaroxaban15 mg orally twice daily with food for 21 days, then 20 mg once daily with food. After day 21 in creatinine clearance 15–49 mL/min, the SmPC allows considering 15 mg once daily if bleeding risk outweighs recurrence risk, but this is pharmacokinetic modelling and was not studied clinically. After at least 6 months, 10 mg once daily (or 20 mg once daily when recurrence risk is high) is licensed for extended prevention.Active bleeding, hepatic disease with coagulopathy and strong interactions. Use caution when creatinine clearance is 15–29 mL/min and do not use below 15 mL/min; the 15 mg and 20 mg doses must be taken with food.
    Open full textbook →Answer 2 questionsCardiology check
    Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • NICE NG158: Venous thromboembolic diseasesCurrent UK diagnosis, interim anticoagulation, treatment and duration route.
    • Resuscitation Council UK 2025 Special circumstancesPE arrest reperfusion and prolonged CPR.
    • Apixaban 5 mg SmPCLicensed acute and extended VTE dosing.
    • Rivaroxaban 10 mg SmPCLicensed VTE loading, maintenance, extended doses and food requirement.
    • Heparin sodium 5,000 units/mL SmPCLicensed PE loading, infusion and APTT monitoring; differs from the RCUK weight-based bolus.
    • Alteplase SmPCLicensed massive-PE dosing and contraindications.

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
  • Use a validated tool plus clinical/social assessment for outpatient treatment, ensuring rapid access if symptoms worsen.