GPAtlas🧭 When to suspect
Suspect a pulmonary embolism (PE) in anyone with sudden or recent:
• Breathlessness
• Pleuritic chest pain
• Cough
• Haemoptysis
The presentation ranges from mild breathlessness to cardiovascular collapse (faintness, syncope, shock), and the diagnosis is frequently missed because a well-looking patient with normal observations can still have a PE.
PE is almost always a complication of underlying venous thromboembolism (VTE), usually a clot embolising from a deep vein thrombosis (DVT). A high index of suspicion is essential when risk factors are present:
• Recent surgery or significant immobility
• Active cancer
• Previous VTE
• Pregnancy or the puerperium
• Combined hormonal contraception or hormone replacement therapy
Estimate clinical probability and direct the pathway accordingly. Use the two-level PE Wells score:
• A likely score (more than 4 points) points to immediate imaging
• An unlikely score (4 points or less) is followed by a D-dimer
Most patients with suspected PE are referred for same-day assessment, but the GP stratifies risk, starts interim anticoagulation when testing is delayed, and must never miss a massive PE.
| Two-level PE Wells score – clinical feature | Points |
|---|---|
| Clinical signs and symptoms of DVT (leg swelling and pain on palpation of the deep veins) | 3 |
| An alternative diagnosis is less likely than PE | 3 |
| Heart rate more than 100 beats per minute | 1.5 |
| Immobilisation for more than 3 days, or surgery in the previous 4 weeks | 1.5 |
| Previous DVT or PE | 1.5 |
| Haemoptysis | 1 |
| Malignancy (on treatment, treated in the last 6 months, or palliative) | 1 |
| PE likely → arrange CT pulmonary angiogram (CTPA) | > 4 |
| PE unlikely → arrange D-dimer | ≤ 4 |
Where overall clinical suspicion is low (gestalt risk under about 15% and other diagnoses are feasible), the PE rule-out criteria (PERC) can be used to decide whether any further PE testing is needed at all.
Source: NICE NG158
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