What is the management of acute pulmonary embolism (PE)?

From the Guidelines

Management of acute pulmonary embolism (PE) requires prompt intervention with anticoagulation as the cornerstone of treatment, with the goal of preventing morbidity, mortality, and improving quality of life. For hemodynamically stable patients with confirmed PE, start low molecular weight heparin (LMWH) such as enoxaparin 1 mg/kg subcutaneously twice daily or fondaparinux 5-10 mg (weight-based) subcutaneously once daily, as recommended by the 2019 ESC guidelines 1. Unfractionated heparin is preferred for patients with severe renal impairment or those who may need thrombolysis, given as an initial bolus of 80 units/kg followed by continuous infusion at 18 units/kg/hour, adjusted to maintain aPTT at 1.5-2.5 times normal, as suggested by the 2014 ESC guidelines 1.

Key Considerations

• Transition to oral anticoagulants should occur within 24-48 hours if the patient is stable, with direct oral anticoagulants (DOACs) like rivaroxaban, apixaban, or edoxaban preferred over warfarin for most patients due to fewer bleeding complications and no need for routine monitoring, as stated in the 2019 ESC guidelines 1.
• For hemodynamically unstable patients with massive PE, systemic thrombolysis with alteplase 100 mg IV over 2 hours should be considered, followed by anticoagulation, as recommended by the 2020 ESC guidelines 1.
• Oxygen supplementation, fluid management, and vasopressors may be necessary for hypotensive patients.
• Anticoagulation should continue for at least 3 months for provoked PE and at least 6-12 months or indefinitely for unprovoked PE, depending on bleeding risk, as suggested by the 2019 ESC guidelines 1.
• Inferior vena cava filters should be reserved for patients with contraindications to anticoagulation or recurrent PE despite adequate anticoagulation.

Treatment Approach

• The treatment approach should be individualized based on the patient's risk factors, comorbidities, and clinical presentation, as emphasized in the 2019 ESC guidelines 1.
• The "Ten Commandments" of the 2019 ESC guidelines provide a comprehensive framework for the diagnosis and management of acute PE, including the importance of prompt anticoagulation, risk assessment, and reperfusion therapy for high-risk patients, as outlined in the guidelines 1.

From the Research

Management of Acute Pulmonary Embolism (PE)

• The initial treatment of haemodynamically stable patients with pulmonary embolism (PE) has dramatically changed since the introduction of low molecular weight heparins (LMWHs) 2.
• Anticoagulation is the cornerstone of acute pulmonary embolism (PE) therapy, and intermediate-risk (submassive) or high-risk (massive) PE patients have higher mortality than low-risk patients 3.
• Low-molecular-weight heparin (LMWH) is at least as effective as unfractionated heparin (UFH) in the treatment of PE, with a similar risk of bleeding 4.

Anticoagulant Therapy

• Direct oral anticoagulant drugs (DOACs) are becoming the agents of first choice for the initial treatment of PE due to their practicability, but many relative contraindications to DOACs were exclusion criteria in clinical trials 2.
• LMWHs will continue to play an important role in initial PE treatment, and in some cases, there still is a role for unfractionated heparin (UFH) 2.
• The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 5.

Treatment Approaches

• Therapeutic approaches depend on a prompt, detailed evaluation, and PE response teams may help with rapid assessment and initiation of therapy 3.
• Surgical pulmonary embolectomy (SPE) remains a vital option for select patients, and systemic anticoagulation is a mainstay of treatment regardless of intervention approach 6.
• Following surgical embolectomy, direct oral anticoagulants (DOACs) have been shown to reduce recurrence of thromboembolism 6.