GPAtlas🧭 When to suspect
Suspect a pulmonary embolism (PE) in anyone with sudden or recent breathlessness, pleuritic chest pain, cough or 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, and combined hormonal contraception or hormone replacement therapy.
The key primary-care skill is to 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, while 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 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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