By: RS Abdi Waluyo
Pulmonary embolism (PE) is a condition in which a blood clot blocks one or more blood vessels in the lungs. The clot most commonly originates from the deep veins of the legs, known as deep vein thrombosis (DVT), and then travels through the bloodstream to the lungs.
The severity of PE can range from mild to life-threatening. A large obstruction can increase pressure in the pulmonary circulation, forcing the right side of the heart to work harder to pump blood. If the heart is unable to compensate, blood pressure may fall, leading to shock or even cardiac arrest.
For this reason, pulmonary embolism requires prompt diagnosis and rapid assessment of disease severity.
Symptoms to Watch For
The symptoms of PE are not always typical. Possible warning signs include:
- Sudden shortness of breath
- Chest pain, particularly when taking a deep breath
- Palpitations or a very rapid heart rate
- Coughing up blood
- Dizziness or fainting
- Swelling or pain in one leg
The risk is higher in patients who have recently undergone surgery or experienced trauma, have been immobilized for prolonged periods, have taken long-distance trips, have cancer or obesity, are pregnant or postpartum, use estrogen therapy, have a previous history of DVT or PE, or have certain blood-clotting disorders.
How Is Pulmonary Embolism Diagnosed?
Doctors do not immediately perform a CT scan on every patient presenting with shortness of breath. The evaluation begins with symptoms, risk factors, physical examination, and an assessment of the clinical probability of PE.
In patients whose probability of PE is not high, a D-dimer test may help determine whether further investigation is required.
If clinical suspicion is sufficiently high, the main imaging examination is CT Pulmonary Angiography (CTPA). This test allows physicians to identify the location and extent of blood clots within the pulmonary arteries.
However, once PE has been identified, another critical question needs to be answered:
“How severe is the pulmonary embolism?”
Doctors assess blood pressure, oxygen requirements, right ventricular function on echocardiography or CT, as well as biomarkers such as troponin and BNP/NT-proBNP. The 2026 AHA/ACC guideline also introduced a new Category A–E classification, ranging from asymptomatic PE to PE associated with cardiopulmonary failure, shock, or cardiac arrest.
Do All Blood Clots Need to Be “Dissolved”?
No.
Anticoagulants, commonly referred to as blood thinners, remain the cornerstone of PE treatment. These medications do not immediately dissolve an existing clot. Instead, they prevent the clot from becoming larger and reduce the formation of new clots, while the body gradually breaks down the existing thrombus.
In stable, low-risk patients, anticoagulation alone is often sufficient. The 2026 guideline also favors direct oral anticoagulants (DOACs) such as apixaban or rivaroxaban over warfarin in eligible patients.
The challenge arises when the clot burden is large and the right side of the heart begins to struggle.
| Treatment | Advantages | Limitations |
| Anticoagulation | Effective for most PE patients and associated with a relatively lower bleeding risk | Does not immediately remove the obstruction |
| Systemic thrombolysis | Can rapidly dissolve clots and may be lifesaving in PE with shock | The medication circulates throughout the body, increasing the risk of major bleeding, including intracranial hemorrhage |
| Surgical embolectomy | Allows direct removal of the clot | More invasive and requires an experienced surgical team and specialized center |
| Catheter-directed therapy | Targets treatment directly within the pulmonary arteries; may use lower doses of thrombolytic medication or mechanically remove the clot | Still an invasive procedure, requires a catheterization laboratory and experienced team, and is not necessary for every patient |
The previous PEITHO trial demonstrated why systemic thrombolysis is not routinely administered to patients with intermediate-risk PE: although it reduced the risk of hemodynamic collapse, it also increased the risk of major bleeding and hemorrhagic stroke.
Modern Treatment: Targeting the Clot Directly from Within the Blood Vessel
Advances in medical technology have made it possible to treat selected cases of pulmonary embolism using catheter-directed therapy.
A catheter is inserted through a vein and advanced into the pulmonary artery where the clot is located. This allows physicians to deliver treatment directly at the site of the thrombus.
One approach is catheter-directed thrombolysis, in which clot-dissolving medication is administered directly into the obstruction. Because the therapy is more targeted, a lower total dose of thrombolytic medication may be required compared with systemic administration.
Certain technologies also combine catheter-based treatment with ultrasound energy to facilitate penetration of the thrombolytic medication into the clot. Another approach is mechanical thrombectomy, in which the clot is aspirated or mechanically removed.
The potential advantages of catheter-based therapy include:
- Treatment directed specifically at the site of the clot
- Potential use of a lower thrombolytic dose
- More rapid reduction of right ventricular strain in selected patients
- A minimally invasive approach compared with open surgery
However, not every patient with PE requires catheter-based intervention. Treatment decisions depend on the patient’s hemodynamic status, right ventricular function, clot burden, oxygen requirements, bleeding risk, and underlying medical conditions.
Pulmonary Embolism Management at RS Abdi Waluyo
Optimal management of pulmonary embolism often requires a multidisciplinary approach, as a patient’s condition can deteriorate rapidly.
At RS Abdi Waluyo, pulmonary embolism can be evaluated and managed comprehensively, from initial diagnosis to advanced treatment, supported by:
- Laboratory testing and cardiac biomarkers
- CT Scan / CT Pulmonary Angiography
- Echocardiography
- ECG and cardiovascular monitoring
- Intensive care in the ICU
- Catheterization Laboratory (Cathlab) and Hybrid Cathlab
- Anticoagulation and thrombolytic therapy
- Catheter-based intervention for pulmonary embolism in appropriately selected patients
- Multidisciplinary support from pulmonology, internal medicine, interventional cardiology, intensive care, radiology, and cardiothoracic surgery teams according to the patient’s clinical needs
RS Abdi Waluyo has two Cathlab facilities, including a Hybrid Cathlab, allowing minimally invasive interventions to be performed with comprehensive cardiovascular imaging and procedural support.
The goal is not simply to remove the clot, but to determine the right treatment for the right patient at the right time.
Do Not Ignore Sudden Shortness of Breath
Pulmonary embolism can progress rapidly, and in some patients there may be no typical warning signs beforehand.
Seek immediate medical evaluation if you experience sudden shortness of breath, chest pain, severe palpitations, fainting, coughing up blood, or swelling in one leg, particularly after surgery, prolonged travel, or a period of reduced mobility.
Early diagnosis, accurate risk stratification, and access to a range of treatment options—from anticoagulation to catheter-based intervention—can play an important role in the successful management of pulmonary embolism.
Referensi
- Creager MA, Barnes GD, Giri J, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults. J Am Coll Cardiol. 2026.
- Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2020;41:543–603.
- Meyer G, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370:1402–1411.
- Kucher N, et al. Randomized controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation. 2014;129:479–486.
- Avgerinos ED, et al. Randomized trial comparing standard versus ultrasound-assisted thrombolysis for submassive pulmonary embolism: SUNSET sPE. JACC Cardiovasc Interv. 2021.
- Giri J, et al. Interventional therapies for acute pulmonary embolism: current status and principles for the development of novel evidence. Circulation. 2019.
