Low risk

• Anticoagulation alone, either inpatient or outpatient

Intermediate low risk

• Anticoagulation 

Intermediate high risk

• Troponin or pro BNP elevation AND RV/LV ratio greater than 0.9. Radiologists will include RV/LV ratio in their dictations if positive for PE on CT scan.

• Anticoagulation first, then first systemic tPA if decompensates; if failed or contraindicated for systemic thrombolysis, user surgical thrombectomy or catheter directed thrombectomy

High risk (massive PE)

• Systemic thrombolysis in patients without contraindication. In patients with failed thrombolysis (clinical deterioration or lack of improvement despite treatment) or contraindication to thrombolysis, user surgical thrombectomy or catheter directed thrombectomy

Note: Even for massive PE’s, IR or surgical thrombectomy IS NOT the initial treatment of choice unless systemic thrombolysis is contraindicated or it has failed.

If shock/hypotension (SBP <90 mm Hg for 15 min) - High Risk

• Systemic thrombolysis unless contra-indicated

• If lytics contra-indicated, consider catheter-assisted thrombus removal or surgical thrombectomy

Is sPESI ≥ 1, or PESI class III, IV, or V?

• If no - Low Risk: recommend systemic anticoagluation

• If Yes, check for RV dysfunction

  • 1. RV/LV > 0.9 on CT or ECHO

    2. Elevated troponin or pro-BNP

• If only one or no sign for RV dysfunction, then Intermediate Low Risk: recommend systemic anticoagulation

• If both are true, then Intermediate High Risk: systemic anticoagulation and close monitoring

• If patient decompensates, use High Risk protocol above