What are the symptoms and treatment options for acute pulmonary embolism (PE)?

From the Guidelines

Acute pulmonary embolism should be treated with anticoagulation, preferably with a non-vitamin K antagonist oral anticoagulant (NOAC) over the traditional low molecular weight heparin (LMWH)-vitamin K antagonist (VKA) regimen, unless contraindicated. This approach is based on the most recent guidelines, including the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) 1. The treatment should be initiated as soon as possible, and the choice of anticoagulant should be based on the patient's individual risk factors and preferences.

Key Considerations

• Anticoagulation with a NOAC is preferred over the traditional LMWH-VKA regimen, unless the patient has contraindications to this type of drug 1.
• The treatment should continue for at least 3-6 months, and the decision to extend or stop anticoagulation should be based on the patient's risk of recurrence and bleeding complications 1.
• For hemodynamically unstable patients with massive PE, consider thrombolytic therapy with alteplase 100 mg IV over 2 hours, as recommended by the 2019 ESC guidelines 1.
• Supplemental oxygen should be provided to maintain oxygen saturation above 90%, and hemodynamic support with IV fluids and vasopressors may be necessary for hypotensive patients.

Follow-up and Monitoring

• Patients should be followed up regularly to monitor for signs of recurrence, bleeding complications, and other potential complications such as chronic thromboembolic pulmonary hypertension (CTEPH) 1.
• Follow-up imaging is not routinely recommended in asymptomatic patients, but it may be considered in patients with risk factors for development of CTEPH 1.
• The patient's quality of life and functional status should be assessed regularly, and treatment should be adjusted accordingly to minimize morbidity and mortality.

From the FDA Drug Label

Heparin Sodium Injection is indicated for: • Prophylaxis and treatment of venous thrombosis and pulmonary embolism; • Prevention of postoperative deep venous thrombosis and pulmonary embolism in patients undergoing major abdominothoracic surgery or who, for other reasons, are at risk of developing thromboembolic disease; • Atrial fibrillation with embolization; • Treatment of acute and chronic consumptive coagulopathies (disseminated intravascular coagulation); • Prevention of clotting in arterial and cardiac surgery; • Prophylaxis and treatment of peripheral arterial embolism. • Anticoagulant use in blood transfusions, extracorporeal circulation, and dialysis procedures.

Heparin is indicated for the treatment of acute pulmonary embolism 2. The recommended dosage for therapeutic anticoagulant effect can be found in Table 1 of the drug label, which includes deep subcutaneous (intrafat) injection and intermittent intravenous injection methods 2.

• Key points for administration include:
  • Confirming the correct formulation and strength of Heparin Sodium Injection
  • Inspecting the solution for particulate matter and discoloration
  • Administering the drug by intermittent intravenous injection, intravenous infusion, or deep subcutaneous injection
  • Avoiding the intramuscular route due to the risk of hematoma
  • Monitoring coagulation tests, such as activated partial thromboplastin time (aPTT), to adjust the dosage as needed 2.

From the Research

Acute Pulmonary Embolism Treatment

• The treatment of acute pulmonary embolism (PE) involves anticoagulation therapy to prevent further clotting and reduce the risk of recurrence 3, 4, 5.
• Hemodynamically unstable patients with PE are typically treated with unfractionated heparin (UFH), while hemodynamically stable patients are treated with low-molecular-weight heparin (LMWH) or fondaparinux 3, 4.
• The use of direct oral anticoagulants (DOACs) has become more prevalent in recent years, and they are now considered a first-line treatment option for PE 6.
• The decision on the duration of anticoagulation therapy should be based on the individual patient's risk of recurrence and bleeding 3.

Anticoagulation Therapy

• LMWH is at least as effective as UFH in the treatment of PE, with a similar risk of bleeding 5.
• DOACs have been shown to be non-inferior to standard therapy for the initial treatment of PE, and they offer a more convenient treatment option 6.
• Therapeutic anticoagulation with LMWH or UFH infusion during catheter-directed thrombolysis for acute PE appears to be safe, with no significant difference in hemorrhagic complication rates between the two treatments 7.

Risk Stratification

• Patients with PE can be stratified into different risk categories based on their clinical presentation and diagnostic test results 4.
• Hemodynamically unstable patients are considered to be at high risk, while hemodynamically stable patients are considered to be at non-high risk 4.
• Further risk stratification can be performed using tests to detect right ventricular dysfunction or myocardial injury, which can indicate intermediate-risk PE 4.

Treatment Duration

• The duration of anticoagulation therapy should be individualized based on the patient's risk of recurrence and bleeding 3.
• Patients with a strong transient risk factor for PE may be able to discontinue anticoagulation therapy after 3 months, while patients with a strong persistent risk factor may require indefinite anticoagulation 3.
• The use of NOACs may allow for extended oral anticoagulation of indefinite duration, even in patients with a low risk of recurrence 3.