The diagnosis of pulmonary embolism (PE) can be very elusive and, if missed, may have fatal consequences. Conversely, PE can be over-diagnosed, with the concomitant risks associated with unnecessary anticoagulation. Although there are many tests that used in the diagnosis of PE, no test can exclude this condition with 100% certainty, and PE has been reported even after a negative pulmonary angiography. The diagnosis of PE depends on the interpretation of the available tests in the context of pre-test clinical probabilities. Ventilation/perfusion (V′/Q′) scan and computerised tomographic pulmonary angiography (CTPA) are the main screening tests used for patients with suspected PE. However, bothV′/Q′ scan and CTPA have to be supplemented by other diagnostic modalities because of their diagnostic limitations. This article reviews the literature concerning the diagnosis of PE, with particular reference to the approach in our acute assessment unit. We conclude by describing two learning points from real cases presenting with suspected PE, in order to highlight how the diagnosis can be missed or made inaccurately.

Objective: Evidence has emerged that out-patient management of pulmonary embolism may be an appropriate option in selected patients. This report is based on a safety data on a Pulmonary Embolism Ambulatory Treatment program. Methods: An observational study in acute assessment unit from 2000-2006, of all consecutive patients with confirmed pulmonary embolism (high probability ventilation-perfusion scan or computerized tomography pulmonary angiography), have been evaluated. Exclusion criteria were oxygen saturation less than 92%; systolic blood pressure less than 100 mm Hg; significant cardiopulmonary or renal disease, and a bleeding risk. Patient treated initially with low molecular weight heparin followed by oral anticoagulants when diagnosis was confirmed and were assessed at 3 and 6 months. Results: Sixty-one patients (33 females), median age 55 (range; 16-89 years) were eligible. Patients needed a maximum of 13 appointments. Risk factors included surgery (8.2%), cancer (8.2%), long travel (14.8%), previous thromboembolism (14.8%), hormonal replacement therapy (3.3%) and contraceptive pill (8.2%). No risk factor was identified at 37.7%. The mortality was zero at 6 months. No complications were recorded. Four patients required hospital admission, all within the first week; all were discharged within 24 hours. The median length of stay for patients with uncomplicated pulmonary embolism was 7 days; implementation of the pulmonary embolism ambulatory treatment program saved 427 bed days. Conclusion: The pulmonary embolism ambulatory treatment program was cost-effective and was not associated with serious complications. Further evaluation of these programs could help establish the safety and cost-effectiveness of this approach.

Objective: Evidence has emerged that out-patient management of pulmonary embolism may be an appropriate option in selected patients. This report is based on a safety data on a Pulmonary Embolism Ambulatory Treatment program. Methods: An observational study in acute assessment unit from 2000-2006, of all consecutive patients with confirmed pulmonary embolism (high probability ventilation-perfusion scan or computerized tomography pulmonary angiography), have been evaluated. Exclusion criteria were oxygen saturation less than 92%; systolic blood pressure less than 100 mm Hg; significant cardiopulmonary or renal disease, and a bleeding risk. Patient treated initially with low molecular weight heparin followed by oral anticoagulants when diagnosis was confirmed and were assessed at 3 and 6 months. Results: Sixty-one patients (33 females), median age 55 (range; 16-89 years) were eligible. Patients needed a maximum of 13 appointments. Risk factors included surgery (8.2%), cancer (8.2%), long travel (14.8%), previous thromboembolism (14.8%), hormonal replacement therapy (3.3%) and contraceptive pill (8.2%). No risk factor was identified at 37.7%. The mortality was zero at 6 months. No complications were recorded. Four patients required hospital admission, all within the first week; all were discharged within 24 hours. The median length of stay for patients with uncomplicated pulmonary embolism was 7 days; implementation of the pulmonary embolism ambulatory treatment program saved 427 bed days. Conclusion: The pulmonary embolism ambulatory treatment program was cost-effective and was not associated with serious complications. Further evaluation of these programs could help establish the safety and cost-effectiveness of this approach.