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Venous Thromboembolism (VTE)

Practice Essentials

Venous thromboembolism (VTE) encompasses two interrelated conditions that are part of the same spectrum, deep vein thrombosis (DVT) and pulmonary embolism (PE) (see the image below). The spectrum of disease ranges from clinically unsuspected to clinically unimportant to massive embolism causing death.

Helical CT scan of the pulmonary arteries. A filli

Helical CT scan of the pulmonary arteries. A filling defect in the right pulmonary artery is present, consistent with a pulmonary embolism.

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Signs and symptoms

Signs and symptoms of thromboembolism include the following:

Acute onset of shortness of breath; dyspnea is the most frequent symptom of PE

Pleuritic chest pain, cough, or hemoptysis (with a smaller PE near the pleura)

Syncope (with a massive PE)

Sense of impending doom, with apprehension and anxiety

Complaints related to signs of DVT, lower-extremity swelling, and warmth to touch or tenderness

Tachypnea (respiratory rate >18 breaths/min)


Accentuated second heart sound


Normal findings from lung examination


See Presentation for more detail.


Workup for thromboembolism includes the following:

Pulmonary angiography: Diagnostic standard for PE

Ventilation-perfusion scanning: Most common screening technique

Venography: Standard test for validating new diagnostic procedures

Arterial blood gas values on room air: Hypoxemia, elevated alveolar-arterial oxygen gradient

Acid-base status: Respiratory alkalosis

Enzyme-linked immunoassay (ELISA) for D-dimer

Electrocardiography, especially for ruling out myocardial infarction

Chest radiography: Most often normal but occasionally suggestive

Helical (spiral) computed tomography of pulmonary vessels

Doppler ultrasonography of venous system


Impedance plethysmography: Of limited value when DVT is asymptomatic or distal or when findings are nonocclusive

See Workup for more detail.


Anticoagulant medications include the following:

Heparin or a low-molecular-weight heparin (LMWH)

Subsequent administration of an oral coumarin derivative (typically, warfarin sodium)

Oral factor Xa inhibitors (eg, rivaroxaban)

Thrombolytic options (for initial treatment of patients with acute, massive PE causing hemodynamic instability) include the following:

Tissue plasminogen activator (t-PA; first-choice thrombolytic agent), including the recombinant agents alteplase, reteplase, and tenecteplase

Streptokinase (risk of antibody development)

Urokinase (of limited availability)

Surgical interventions include the following:


Embolectomy (limited to massive PE when thrombolysis is contraindicated or other treatments have failed)

Venous interruption (currently rare)


Thromboprophylaxis reduces the incidence of DVT and fatal PE and may be achieved by pharmacologic or mechanical means. Medications used for prevention of thromboembolism include the following:

Unfractionated heparin




Direct oral anticoagulants


Mechanical approaches to thromboprophylaxis include the following:

External compression

Early ambulation

See Treatment and Medication for more detail.

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