Acute pulmonary embolism (PE) is of interest to physicians of almost all disciplines, as it is encountered across the entire spectrum of clinical medicine. It is estimated that as many as 200 000 patients die annually from PE in the European Union, with similar numbers reported in the USA. In the past, management of acute PE has been characterised by a high degree of complexity and a disappointing lack of efficacy and efficiency. Complex multistep diagnostic algorithms were successfully tested in management studies, but proved extremely difficult to implement correctly in clinical practice. As a result, the diagnosis of PE was frequently missed in patients who subsequently died of the disease without receiving appropriate treatment, while others unnecessarily underwent hazardous, time consuming and costly procedures because of a vague, poorly documented clinical suspicion. With regard to PE treatment, a more than 30-year-old debate and the lack of adequate data on the appropriate indications for thrombolysis have deprived some patients of potentially life saving treatment, while exposing others to the high bleeding risk of thrombolytic drugs.

Thanks to the technical advances in diagnostic modalities and the findings of recent well designed outcome studies, things are now beginning to look better for patients with PE and for the physicians caring for them. While the revised and updated guidelines of the European Society of Cardiology on the diagnosis and treatment of PE are expected to appear later this year, this review will summarise the relevant current and evolving concepts which already have begun to simplify the management of acute PE while, at the same time, increasing its efficacy and safety.

DIAGNOSTIC STRATEGIES AND ALGORITHMS

At present, there is only one clinical factor which unequivocally determines the diagnostic and therapeutic approach to a patient with suspected acute PE: the presence or absence of haemodynamic instability at presentation. Acute right …