What is the management of pulmonary embolism (PE)?

From the Guidelines

Pulmonary embolism management should prioritize anticoagulation with unfractionated heparin (UFH) and consideration of systemic thrombolytic therapy for high-risk patients, as recommended by the 2019 ESC guidelines 1. The management of pulmonary embolism (PE) requires a multifaceted approach, taking into account the patient's risk stratification and clinical presentation.

• For high-risk PE, anticoagulation with UFH, including a weight-adjusted bolus injection, should be initiated without delay 1.
• Systemic thrombolytic therapy is also recommended for high-risk PE, as it has been shown to improve outcomes in these patients 1.
• In patients with high-risk PE, surgical pulmonary embolectomy may be considered if thrombolysis is contraindicated or has failed 1.
• Additionally, percutaneous catheter-directed treatment and the use of norepinephrine and/or dobutamine may be considered in specific cases 1. The use of 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. It is essential to note that the management of PE should be individualized, taking into account the patient's underlying risk factors, clinical presentation, and potential contraindications to certain treatments.
• The 2014 ESC guidelines also emphasize the importance of prompt anticoagulation and consideration of thrombolytic therapy in high-risk PE patients 1. However, the 2019 guidelines provide more comprehensive and up-to-date recommendations, and therefore, should be prioritized in clinical practice.
• The key to effective PE management is prompt recognition, risk stratification, and initiation of appropriate treatment to improve patient outcomes and reduce morbidity and mortality.

From the FDA Drug Label

1.3 Treatment of Pulmonary Embolism

XARELTO is indicated for the treatment of pulmonary embolism (PE).

1.4 Reduction in the Risk of Recurrence of Deep Vein Thrombosis and/or Pulmonary Embolism

XARELTO is indicated for the reduction in the risk of recurrence of DVT and/or PE in adult patients at continued risk for recurrent DVT and/or PE after completion of initial treatment lasting at least 6 months.

1.3 Treatment of Pulmonary Embolism

Apixaban tablets are indicated for the treatment of PE.

1.5 Reduction in the Risk of Recurrence of DVT and PE

Apixaban tablets are indicated to reduce the risk of recurrent DVT and PE following initial therapy.

Pulmonary Embolism Management: Rivaroxaban (XARELTO) and apixaban are indicated for the treatment of pulmonary embolism (PE) and reduction in the risk of recurrence of PE.

• Rivaroxaban: is used to treat PE and reduce the risk of recurrence of DVT and/or PE in adult patients at continued risk for recurrent DVT and/or PE after completion of initial treatment lasting at least 6 months 2.
• Apixaban: is used to treat PE and reduce the risk of recurrent DVT and PE following initial therapy 3.

From the Research

Pulmonary Embolism Management

• Pulmonary embolism (PE) is characterized by occlusion of blood flow in a pulmonary artery, typically due to a thrombus that travels from a vein in a lower limb 4.
• The incidence of PE is approximately 60 to 120 per 100 000 people per year, with approximately 60 000 to 100 000 patients dying from PE each year in the US 4.
• PE should be considered in patients presenting with acute chest pain, shortness of breath, or syncope, and diagnosis is determined by chest imaging 4.

Diagnosis and Evaluation

• In patients with a systolic blood pressure of at least 90 mm Hg, the following 3 steps can be used to evaluate a patient with possible PE: assessment of the clinical probability of PE, D-dimer testing if indicated, and chest imaging if indicated 4.
• The clinical probability of PE can be assessed using a structured score or using clinical gestalt, and patients with a probability of PE that is less than 15% may not require further testing 4.
• D-dimer testing can be used to exclude PE in patients with low or intermediate clinical probability, with a D-dimer level of less than 500 ng/mL associated with a posttest probability of PE less than 1.85% 4.

Treatment

• First-line therapy for PE consists of direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, with thrombolysis reserved for patients with systolic blood pressure lower than 90 mm Hg 4, 5.
• Anticoagulation is performed with unfractionated heparin (UFH) in hemodynamically unstable patients and with low molecular weight heparins (LWMH) or fondaparinux in normotensive patients 5.
• The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding, with extended oral anticoagulation of indefinite duration considered for patients with intermediate risk of recurrence 5, 6.

Risk Stratification and Management

• Risk stratification is crucial to decide the best management and treatment strategy for PE, with home therapy an option for low-risk patients and hospitalization required for patients at intermediate risk 6.
• Patients with high or intermediate clinical probability of PE should undergo chest imaging, and D-dimer testing is not necessary 4.
• Systemic thrombolysis is recommended for patients with PE and systolic blood pressure lower than 90 mm Hg, and is associated with an absolute reduction of mortality 4, 7.
• Catheter-assisted thrombus removal and surgical embolectomy are also treatment options for intermediate and high-risk PE 7.