Pulmonary embolism updates for GPs: new options for massive PE, Wells and PERC, and the age-adjusted D-dimer

Speaker

Emergency clinician at Pindara Private Hospital, Gold Coast (presenter not named in the recording; role inferred from the case — the patient “came into the emergency department of Pindara” and the speaker “spoke to the cardiologist”). No sponsor statement was captured.

Others named

The treating interventional cardiologist is named on the ASR as “Shalesh Kotha” (spelling as captured, unconfirmed), talked through the procedure by a second cardiologist. The patient — a colleague of the speaker — is not named. The Gold Coast University Hospital (GCUH) ECMO and interventional teams are referred to by team only.

Session context

Otter title PE Treatment Updates · id FLLESVc1dI5vnvWT6Bi5RMf_pmY · ~20 min, recorded 21 March 2026 9:52 am AEST — the same morning as the hypertension in pregnancy talk. All speakers are labelled “Unknown Speaker” / Speaker 1–5. The speaker ran short of time and skipped the planned case examples; the recording ends mid-question.

Key messages for GPs

• Massive PE means haemodynamic compromise — hypotension or cardiac arrest. It is rarely what walks into a GP clinic.
• New interventions exist for the sickest patients: catheter-directed (local) thrombolysis, ECMO, and endovascular suction thrombectomy — on top of standard systemic thrombolysis. Evidence is still limited.
• These are for a tiny fraction of PE — the speaker compared it with stroke thrombectomy, which is done in about 1% of stroke presentations (as stated). Not every PE needs to go to the tertiary centre “just in case”.
• For suspected PE, start with your clinical gestalt, then apply a decision tool such as the Wells score.
• High risk → go straight to CTPA. A negative D-dimer won’t change your plan.
• Low risk → consider PERC. If all PERC items are negative, PE is ruled out without testing.
• Moderate risk is where the D-dimer earns its keep — and over 50, use an age-adjusted cut-off (age × 10, e.g. 0.6 at age 60 in units where 0.5 is the usual cut-off).

What counts as massive PE?

The speaker started with something that has been changing recently: management of massive PE. “By definition” it is hypotensive — cardiovascular compromise, hypotension or cardiac arrest. “These aren’t the things that you’re going to see in the GP’s rooms.”

The case: a colleague in cardiac arrest

A man came into the Pindara emergency department clutching his chest, pale, and looking as if he was about to arrest. All he managed to say was that he had chest pain. He turned out to be one of the speaker’s colleagues. After a brief exchange and an ECG, he had a cardiac arrest.

• The dilemma: the ECG did not look like a STEMI to the speaker, who suspected PE. But a STEMI was the one thing that could be fixed immediately in the cath lab. With the cardiologist, the team decided to go to the lab anyway: “if it was a STEMI, we could fix it and save him. If it wasn’t, [he] was probably going to be toast anyway.”
• Why not thrombolyse first? Systemic thrombolysis before the cath lab would have increased bleeding risk if this had turned out to be an MI needing intervention. And the lab could look at the coronaries “within five minutes”.
• In the lab: coronaries were clear. An on-table echo showed significant right heart strain — what you see with a saddle embolus pressing on the right side of the heart — so PE was probable.
• Catheter-directed thrombolysis: at another cardiologist’s suggestion, the interventional cardiologist — who had never done it before, and was talked through it — passed a wire through the right heart, past the clot, restoring some perfusion, and delivered localised thrombolysis at the clot. Access was through the venous side (via the IVC and up through the right heart) rather than the usual arterial route to the coronaries.
• Systemic thrombolysis was then also given — the other standard treatment for massive PE in cardiac arrest. He regained some output but remained very sick in ICU.
• ECMO retrieval: ECMO is not provided in the private sector — “it’s a big enterprise” — but GCUH offers it. He was too sick to move conventionally, so the GCUH team (the speaker mentioned three intensivists) came out and placed him on ECMO, using the ambulance “just as the taxi cab”. The speaker said it was that team’s first ECMO retrieval.
• Endovascular thrombectomy at GCUH: the clots were sucked out (a photo of the clots was shown). The speaker described this as one of the earlier interventional thrombectomies at GCUH for this indication; the team later presented it at a conference.
• Outcome: he did very well and is back at work. “I thought he was going to die on us.”

Emerging options for massive PE

What about less severe PE?

For lower-grade PE there is mixed evidence for thrombectomy and little long-term evidence of meaningful overall benefit. “If you’ve got a hammer in your hand, everything looks like a nail” — interventionalists may favour it, but “we’re just waiting for the evidence to come through.”

Is there a set pathway?

Asked whether thrombectomy is reserved for failed thrombolysis, the speaker said there is no set pathway yet. Massive PE often presents as cardiac arrest, so thrombolysis comes first; survivors who remain unstable may be those in whom clot retrieval is tried, to reduce clot burden and offload the right heart. There are too many individual variables to define the right strategy. An audience member suggested a time window, as with stroke (e.g. after 12 hours); the speaker agreed that “may emerge”.

Why this is for very few patients

The speaker stressed that these interventions concern “the uppermost points of a percent of everybody who has PE”. The stroke parallel: private hospitals now see few strokes because everyone goes to GCUH “just in case” they need an endovascular procedure — yet those procedures are done in about 1% of stroke presentations (as stated). The speaker does not want PE to go the same way: “it’s only very few patients that this is necessary” for.

Assessing suspected PE: pretest probability first

The planned section on lower-acuity PE was “a 20-minute talk in its own right”, so the speaker fast-forwarded to the key steps. PE assessment is well described in the literature and is a model for thinking about many conditions:

1. Pretest probability. After the history and examination, “your brain is saying, I don’t think this patient has got a PE, or I really think this patient has got a PE.” That medical reasoning (gestalt) comes first.
2. Apply a decision tool to modify that estimate — most commonly the Wells score. The speaker uses MDCalc when needed but knows the items well enough to sort patients into low, moderate or high risk.

Wells score: low, moderate or high

Wells is helpful because it quantifies risk. As the speaker gave it:

PERC: ruling out without a test

Because “we get very scared in medical practice these days” and are under a lot of criticism, there are further rules for very low-risk patients. The PERC rule (pulmonary embolism rule-out criteria; ASR “per call”) is a set of questions, also on MDCalc. If you judge the patient low risk and all PERC questions are negative, that is enough to rule out PE without any further testing. The ones you cannot rule out this way usually end up in the moderate-risk group. (The individual PERC items were shown on a slide but not read out.)

D-dimer: know what you’ll do with the result

The speaker’s memorable analogies — “poking the skunk” or “picking your nose in public” — make the same point: if you order a D-dimer and get a positive result you didn’t really want, you are forced down a pathway of further tests.

Teaching note: the speaker summarised low specificity as “if you get a positive result, there’s 40% chance that it’s due to the PE”. Strictly, specificity is the proportion of people without PE who test negative; the chance that a positive result is truly PE (the positive predictive value) depends on the pretest probability — which is exactly why the speaker’s pretest-first approach matters.

Age-adjusted D-dimer cut-offs

This is the “new” item the speaker most wanted to share: something used for the last few years and “borne out in the literature”. As we age, there is more clot formation and breakdown in the circulation, so the D-dimer rises.

• Check how your lab reports it: some report the usual cut-off as a decimal (e.g. 0.5) and some as hundreds (e.g. 500) — “look at what the numbers are for you” (the transcript also mentions “point four”; that figure is unclear).
• Over 50, the cut-off becomes age × 10 in the hundreds-style units (or age ÷ 100 in the decimal style): 0.5 at 50, 0.6 at 60, 0.7 at 70, 0.8 at 80.
• The speaker’s department uses this actively: a “positive” D-dimer is checked against the age-adjusted cut-off.

Is it safe? Asked whether a 60-year-old with a D-dimer of 0.6 definitely does not have PE, the speaker said there are supporting studies. They did not CTPA everybody; instead patients were followed up to make sure PEs were not missed. It has been “tested and restudied” and is commonly accepted — “prime time”.

The YEARS approach

The speaker briefly mentioned the YEARS criteria (ASR “years criteria”), which has “come up recently in the literature”:

• It uses only three questions.
• If the patient has none of them and a D-dimer has been done, the rule-out cut-off can be raised to 1000 (or 1.0).
• The speaker does not use it personally (the reason was not given) and suggested looking it up rather than copying it from the slide — the three items were not read out.

GP clinic checklist

1. Haemodynamic compromise (hypotension, collapse, arrest) with suspected PE → emergency: call an ambulance and arrange immediate ED care.
2. For a stable patient, form your gestalt from the history and examination first.
3. Calculate a Wells score (MDCalc is fine).
4. High risk → CTPA (via ED or urgent imaging, per local pathway); don’t rely on a D-dimer.
5. Low risk → apply PERC. All negative → PE ruled out; no D-dimer needed.
6. Moderate risk (or PERC-positive low risk) → D-dimer.
7. Before ordering, decide what you will do with a positive result — and where the patient will get a CTPA.
8. Over 50, interpret the D-dimer against age × 10 in your lab’s units (0.6 at 60, 0.7 at 70, 0.8 at 80).
9. Know that YEARS exists (three questions, higher cut-off of 1000 when none are present); look up the items before using it.
10. Massive-PE interventions (local lysis, ECMO, thrombectomy) are tertiary options for very few patients — routine PE does not need transfer “just in case”.

Transcript caveats

allcpd.drkotha.com · directory