What is the management of a patient with haemodynamically unstable Acute Pulmonary Embolism (APE)?

From the Guidelines

Management of haemodynamically unstable acute pulmonary embolism (APO) requires immediate initiation of anticoagulation with unfractionated heparin (UFH) and consideration of systemic thrombolytic therapy. The 2020 ESC guidelines recommend anticoagulation with UFH, including a weight-adjusted bolus injection, to be initiated without delay in patients with high-risk PE 1.

Initial Management

• Initiate anticoagulation with UFH, including a weight-adjusted bolus injection, as soon as possible 1
• Consider systemic thrombolytic therapy for high-risk PE, as recommended by the 2020 ESC guidelines 1
• Surgical pulmonary embolectomy is recommended for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed 1

Supportive Care

• Consider norepinephrine and/or dobutamine for patients with high-risk PE, as recommended by the 2020 ESC guidelines 1
• Percutaneous catheter-directed treatment may be considered for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed 1
• Extracorporeal membrane oxygenation (ECMO) may be considered, in combination with surgical embolectomy or catheter-directed treatment, in patients with PE and refractory circulatory collapse or cardiac arrest 1

Ongoing Management

• After haemodynamic stabilization of the patient, continue with anticoagulation treatment as in intermediate- or low-risk PE 1
• The underlying cause of APO must be identified and treated simultaneously, whether it's acute coronary syndrome, arrhythmia, or valve dysfunction.
• Continuous cardiac monitoring, frequent vital sign checks, and arterial blood gas analysis are essential to guide management and adjust treatment as needed.

From the FDA Drug Label

FULL PRESCRIBING INFORMATION 1 INDICATIONS AND USAGE 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.

The management of haemodynamically unstable Acute Pulmonary Embolism (APO) is not directly addressed in the provided drug label for heparin. Key points to consider in the management of APO include:

• The drug label does provide information on the treatment of pulmonary embolism, but it does not specifically address the management of haemodynamically unstable patients.
• The label recommends adjusting the dosage of heparin according to the patient's coagulation test results, but it does not provide guidance on the management of haemodynamically unstable patients.
• The label does provide information on the administration of heparin, including the recommended dosages and frequencies, but it does not address the specific needs of haemodynamically unstable patients 2.

From the Research

Management of Haemodynamically Unstable Acute Pulmonary Embolism (APO)

• Haemodynamically unstable patients with APO require immediate attention and treatment to prevent further deterioration and improve outcomes 3, 4, 5.
• Initial management strategies should focus on optimization of right ventricle (RV) function, including the use of vasoactive agents such as norepinephrine and vasopressin 3.
• IV loop diuretics may be useful if evidence of RV dysfunction or volume overload is present, while fluids should be given only if concern exists for hypovolemia and absence of RV dilatation 3.
• Supplemental oxygen administration should be considered even without hypoxemia, and positive pressure ventilation should be avoided if possible 3.
• Thrombolysis is recommended for haemodynamically unstable patients with APO, unless absolutely contraindicated 4, 5, 6.
• Catheter-directed thrombolysis and surgical embolectomy are also treatment options for select patients with APO 6, 7.
• Anticoagulation remains the foundation of APO management, with direct oral anticoagulants (DOACs) becoming an alternative to vitamin K antagonists 4, 7.

Treatment Options

• Systemic thrombolysis: used as a first-line treatment for haemodynamically unstable patients with APO 4, 5, 6.
• Catheter-directed thrombolysis: a treatment option for select patients with APO, particularly those who are not candidates for systemic thrombolysis 6.
• Surgical embolectomy: a vital option for select patients with APO, particularly those who are not candidates for thrombolysis or have contraindications to anticoagulation 7.
• Anticoagulation: a mainstay of treatment for APO, regardless of intervention approach 4, 5, 7.