What is the management of Pulmonary Embolism (PE)?

From the Guidelines

Management of pulmonary embolism (PE) requires prompt anticoagulation therapy to prevent clot propagation and recurrence, and the most recent guidelines recommend instituting anticoagulation therapy as soon as possible, while the diagnostic workup is ongoing, unless the patient is bleeding or has absolute contraindications 1.

Key Recommendations

• For most patients with confirmed PE, start with parenteral anticoagulation using either low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) like rivaroxaban or apixaban, as recommended by the 2019 ESC guidelines 1.
• Treatment duration is typically 3-6 months for provoked PE and at least 6-12 months or indefinite for unprovoked PE.
• For hemodynamically unstable patients with massive PE, consider systemic thrombolysis with alteplase or catheter-directed thrombolysis in selected cases, as recommended by the 2020 ESC guidelines 1.

Anticoagulation Therapy

• Prefer anticoagulation with a NOAC over the LMWH–VKA regimen unless the patient has contraindications to NOACs 1.
• Use recommended, validated diagnostic algorithms for PE, including standardized assessment of (pre-test) clinical probability and D-dimer testing 1.

Special Considerations

• For patients with contraindications to anticoagulation, inferior vena cava filters should be considered.
• Hemodynamic and respiratory support may be necessary, including oxygen supplementation, fluid management, and vasopressors if needed.
• After acute PE, patients should not be lost to follow-up, and regular follow-up examinations are recommended to check for possible signs of VTE recurrence, cancer, or bleeding complications of anticoagulation 1.

From the FDA Drug Label

1.3 Treatment of Pulmonary Embolism Apixaban tablets are indicated for the treatment of PE.

1.3 Treatment of Pulmonary Embolism XARELTO is indicated for the treatment of pulmonary embolism (PE).

The management of Pulmonary Embolism (PE) can be done using apixaban or rivaroxaban.

• Apixaban is indicated for the treatment of PE, with a recommended dose of 10 mg taken orally twice daily for the first 7 days of therapy, followed by 5 mg taken orally twice daily 2.
• Rivaroxaban is also indicated for the treatment of PE, with a recommended dose of 15 mg taken orally twice daily for the first 21 days, followed by 20 mg taken orally once daily 3 3. Key points to consider when managing PE with these medications include:
• The recommended dosage and duration of treatment
• The need for monitoring and potential dose adjustments based on renal function and other factors
• The risk of thrombotic events and bleeding complications associated with these medications.

From the Research

Management of Pulmonary Embolism (PE)

• The management of PE involves anticoagulation therapy, with direct oral anticoagulants being the preferred choice 4, 5.
• In special populations, such as breastfeeding mothers, those with end-stage renal disease, or obese patients, vitamin K antagonists and low-molecular-weight heparin may be preferred 4.
• The diagnosis of PE is determined by chest imaging, and the clinical probability of PE can be assessed using a structured score or clinical gestalt 5.
• In patients with a high probability of PE, chest imaging is necessary, while in those with a low or intermediate clinical probability, a D-dimer level of less than 500 ng/mL can exclude PE without chest imaging 5.

Anticoagulation Management

• The use of anti-factor Xa assay to monitor heparin therapy in PE patients allows for timely and sustained therapeutic anticoagulation 6.
• A therapeutic antiXa level of 0.3-0.7 units/mL is associated with a low incidence of recurrent thromboembolism and PE-associated mortality 6.
• Direct oral anticoagulants, 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 5.

Thrombolytic Therapy

• Thrombolytic agents, such as alteplase, reteplase, streptokinase, and urokinase, appear to be superior in efficacy compared to anticoagulants alone in reducing mortality and recurrence of PE 7.
• Alteplase may be a better choice due to its ability to reduce mortality, recurrence rate, and pulmonary artery systolic pressure (PASP) 7.
• Tenecteplase may not be a good choice due to an increase in minor bleeding compared to streptokinase and anticoagulants alone 7.

Contemporary Management

• The optimal management of PE patients is a clinical conundrum, and novel interventional techniques, such as catheter-directed thrombolysis and mechanical thrombectomy, have been developed to facilitate reperfusion while mitigating the risk of bleeding 8.
• Systemic thrombolysis is recommended for high-risk PE complicated by hemodynamic instability, while anticoagulation alone remains the standard treatment for hemodynamically stable patients with right ventricular dysfunction 8.