Patient Management Recommendations

• Level A: None specified.
• Level B: For patients who are at low risk for acute PE, use the Pulmonary Embolism Rule-out Criteria (PERC) to exclude the diagnosis without further diagnostic testing.
• Level C: None specified.

Question 2. In adult patients with low to intermediate pretest probability for acute PE, does a negative age-adjusted D-dimer result identify a group of patients at very low risk for the diagnosis of PE for whom no additional diagnostic workup is required?

Patient Management Recommendations

• Level A recommendations: None specified.
• Level B recommendations: In patients older than 50 years deemed to be at low or intermediate risk for acute PE, clinicians may use a negative age-adjusted D-dimer result to exclude the diagnosis of PE. For highly sensitive D-dimer assays using fibrin equivalent units (FEUs), use a cutoff of age × 10 µg/L; for highly sensitive D-dimer assays using D-dimer units (DDUs), use a cutoff of age × 5 µg/L.
• Level C recommendations: None specified.

Question 3. In adult patients with subsegmental PE, is it safe to withhold anticoagulation?

Patient Management Recommendations

• Level A recommendations: None specified.
• Level B recommendations: None specified.
• Level C recommendations: Given the lack of evidence, anticoagulation treatment decisions for patients with subsegmental PE without associated DVT should be guided by individual patient risk profiles and preferences (consensus recommendation).

Question 4. In adult patients diagnosed with acute PE, is initiation of anticoagulation and discharge from the emergency department safe?

Patient Management Recommendations

• Level A recommendations: None specified.
• Level B recommendations: None specified.
• Level C recommendations: Selected patients with acute PE who are at low risk for adverse outcomes as determined by Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), or the Hestia criteria may be safely discharged from the emergency department on anticoagulation, with close outpatient follow-up.

Question 5. In adult patients diagnosed with acute lower-extremity DVT who are discharged from the emergency department, is treatment with a NOAC safe and effective compared with treatment with low-molecular-weight heparin (LMWH) and a vitamin K antagonist (VKA)?

Patient Management Recommendations

• Level A recommendations: None specified.
• Level B recommendations: In selected patients diagnosed with acute DVT, a NOAC may be used as a safe and effective treatment alternative to LMWH/VKA.
• Level C recommendations: Selected patients with acute DVT may be safely treated with a NOAC and directly discharged from the emergency department.

In summary, the evaluation and management of patients with suspected VTE in the emergency department is rapidly evolving and increasingly nuanced. Newer clinical algorithms using PERC and age-adjusted D-dimer may improve the efficiency and effectiveness of evaluations. Similarly, advances in the understanding of whom to treat, in which setting and with what optimal therapy can improve patient-centered outcomes.