The following are key points to remember about this clinical case on pulmonary embolism (PE):

1. Although approximately 20% of patients who are treated for PE die within 90 days, true short-term mortality attributed to PE is estimated to be <5%. Approximately 50% of the patients who receive a diagnosis of PE have functional and exercise limitations 1 year later (known as post–PE syndrome), and the health-related quality of life for patients with a history of PE is diminished as compared with that of matched controls.
2. Newer approaches such as YEARS algorithm and age adjustment for D-dimer thresholds for ruling out PE are recommended.
3. Diagnostic chest imaging is reserved for patients in whom PE cannot be ruled out based on clinical decision making.
4. After initial diagnosis, clinical risk stratification into high, intermediate high risk, intermediate low risk, and low risk is recommended next. The nomenclature of “massive” and “submassive” in describing PE is confusing, given that clot size does not dictate therapy.
5. High risk: Intravenous systemic thrombolysis is the most readily available reperfusion option in high-risk PE patients. Alternative reperfusion approaches include surgical thrombectomy and catheter-directed thrombolysis (with or without thrombectomy). Additional supportive measures include the administration of inotropes and the use of extracorporeal life support.
6. Intermediate high risk: When available, catheter-directed thrombus removal remains an option for such. At this time, there is insufficient evidence to support catheter-directed thrombolysis over anticoagulation alone in these patients. Systemic thrombolysis is not typically recommended for these patients.
7. Intermediate low risk: Anticoagulation with low molecular weight heparin and close monitoring for 24-48 hours for clinical worsening is recommended.
8. Low risk: Outpatient management with direct oral anticoagulants is the preferred strategy.
9. All patients with acute PE should receive anticoagulant therapy for ≥3 months. The decision to continue treatment indefinitely depends on whether the associated reduction in the risk of recurrent venous thromboembolism outweighs the increased risk of bleeding and should take into account patient preferences.
10. Patients should be followed longitudinally after an acute PE to assess for dyspnea or functional limitation, which may indicate the development of post–PE syndrome or chronic thromboembolic pulmonary hypertension.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Interventions and Imaging, Interventions and Vascular Medicine

Keywords: Anticoagulants, Diagnostic Imaging, Dyspnea, Extracorporeal Membrane Oxygenation, Heparin, Low-Molecular-Weight, Outpatients, Pulmonary Embolism, Quality of Life, Reperfusion, Risk Assessment, Secondary Prevention, Thrombectomy, Thrombolytic Therapy, Thrombosis, Vascular Diseases, Venous Thromboembolism

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