What are the interventions for pulmonary embolism (PE)?

From the Guidelines

Pulmonary embolism intervention should prioritize anticoagulation therapy with unfractionated heparin, including a weight-adjusted bolus injection, initiated without delay in patients with high-risk PE, as recommended by the 2019 ESC guidelines 1.

Key Recommendations

• For high-risk pulmonary embolism, systemic thrombolytic therapy is recommended 1, and surgical pulmonary embolectomy is recommended for patients in whom thrombolysis is contraindicated or has failed 1.
• Percutaneous catheter-directed treatment should be considered for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed 1.
• Anticoagulation with UFH, including a weight-adjusted bolus injection, should be initiated without delay in patients with high-risk PE 1.

Treatment Approach

• The treatment approach for pulmonary embolism should be based on the patient's risk stratification, with high-risk patients requiring more aggressive treatment, including thrombolytic therapy or surgical embolectomy 1.
• For non-high-risk pulmonary embolism, anticoagulation with LMWH or fondaparinux is the recommended initial treatment 1.
• The use of inferior vena cava filters should be reserved for patients with contraindications to anticoagulation or recurrent PE despite adequate anticoagulation 1.

Important Considerations

• The 2019 ESC guidelines provide the most recent and highest quality evidence for the management of pulmonary embolism, and should be followed in clinical practice 1.
• The choice of anticoagulant and the duration of treatment should be individualized based on the patient's risk factors and clinical presentation 1.
• Close monitoring and follow-up are essential to ensure the effectiveness of treatment and to prevent complications 1.

From the FDA Drug Label

The primary efficacy endpoint was confirmed, symptomatic, recurrent VTE reported up to Day 97. The efficacy data are provided in Table 13. Table 13. Efficacy of Fondaparinux Sodium in the Treatment of Pulmonary Embolism (All Randomized) EndpointFondaparinux Sodium5, 7.5, or 10 mg SC once dailyN = 1,103HeparinaPTT adjusted IVN = 1,110 n% (95% CI)n% (95% CI) Total VTEa423.8% (2.8,5.1)565.0% (3.8,6. 5) DVT only121.1% (0.6,1.9)171.5% (0.9,2.4) Non-fatal PE141.3% (0.7,2.1)242.2% (1.4,3.2) Fatal PE161.5% (0.8,2.3)151.4% (0.8,2.2) a VTE was a composite of symptomatic recurrent non-fatal VTE or fatal PE reported up to Day 97. The 95% confidence interval for the treatment difference for total VTE was: (-3.0% to 0.5%). During the initial treatment period, 12 (1. 1%) of patients treated with fondaparinux sodium and 19 (1.7%) of patients treated with heparin had a VTE endpoint (95% CI for the treatment difference [fondaparinux sodium-heparin] for VTE rates: -1.6%; 0.4%).

Pulmonary Embolism Intervention: Fondaparinux sodium is used for the treatment of pulmonary embolism.

• The recommended dose is 5 mg (body weight <50 kg), 7.5 mg (body weight 50 to 100 kg), or 10 mg (body weight >100 kg) SC once daily.
• Treatment is usually continued for at least 5 days, with a treatment duration range of 7 ± 2 days.
• Fondaparinux sodium is used in combination with vitamin K antagonist therapy, which is initiated within 72 hours after the first study drug administration and continued for 90 ± 7 days, with regular dose adjustments to achieve an INR of 2 to 3.
• The efficacy of fondaparinux sodium in the treatment of pulmonary embolism is comparable to heparin, with a total VTE rate of 3.8% (95% CI: 2.8,5.1) for fondaparinux sodium and 5.0% (95% CI: 3.8,6.5) for heparin 2.

From the Research

Pulmonary Embolism Intervention

• Pulmonary embolism (PE) is a major clinical problem associated with considerable mortality and morbidity 3.
• Appropriate anticoagulant therapy has been shown to significantly reduce both recurrence and mortality in patients with PE 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 3, 4, 5.

Treatment Options

• LMWH offers more predictable pharmacokinetics and anticoagulant effects compared to UFH 3.
• Outpatient treatment with LMWH has been shown to be feasible in many patients, and offers the potential for cost-savings and improvements in health-related quality of life 3.
• Direct oral anticoagulants (DOACs) such as apixaban, edoxaban, rivaroxaban, or dabigatran are noninferior to heparin combined with a vitamin K antagonist for treating PE, and have a lower rate of bleeding 6.
• Systemic thrombolysis is recommended for patients with PE and systolic blood pressure lower than 90 mm Hg, and is associated with a reduction in mortality 6.

Anticoagulation Therapy

• All patients with PE require therapeutic anticoagulation for at least three months 7.
• The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 7.
• Extended oral anticoagulation of indefinite duration should be considered for all patients with intermediate risk of recurrence, given the favourable safety profile of DOACs 7.

Clinical Practice Guidelines

• Current guidelines from both the American College of Chest Physicians and the joint American College of Physicians/American Academy of Family Physicians recommend the use of LMWH over UFH in patients with submassive PE 3.
• Clinical practice guidelines largely agree on the use of LMWH or fondaparinux as initial therapy for most patients with deep venous thrombosis or pulmonary embolism 4.
• The European Society of Cardiology (ESC) recommends that all eligible patients should be treated with a non-vitamin K antagonist oral anticoagulant (NOAC) in preference to a vitamin K antagonist (VKA) 7.