What is the initial management of tachycardia due to pulmonary embolism (PE)?

From the Guidelines

The initial management of tachycardia due to pulmonary embolism (PE) should focus on hemodynamic stabilization, anticoagulation, and addressing the underlying embolism, with anticoagulation with unfractionated heparin (UFH) or low molecular weight heparin (LMWH) being initiated without delay, as recommended by the 2019 ESC guidelines 1. The management approach depends on the patient's hemodynamic status. For hemodynamically stable patients with tachycardia from PE, immediate therapeutic anticoagulation with UFH (initial bolus of 80 units/kg followed by continuous infusion at 18 units/kg/hr, adjusted to maintain aPTT at 1.5-2.5 times normal) or LMWH (enoxaparin 1 mg/kg subcutaneously twice daily) should be initiated, as suggested by the guidelines 1. Some key points to consider in the management of tachycardia due to PE include:

• Providing supplemental oxygen to maintain oxygen saturation above 90%
• Fluid resuscitation with crystalloids (500-1000 mL) to improve right ventricular filling if hypotension is present
• Considering vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min) for hemodynamically unstable patients with obstructive shock, while arranging for reperfusion therapy 1
• Thrombolytic therapy with alteplase (100 mg IV over 2 hours) for massive PE with hemodynamic compromise, as recommended by the guidelines 1 The tachycardia in PE results from right heart strain, hypoxemia, and compensatory mechanisms to maintain cardiac output despite reduced ventricular filling, making specific rate control medications potentially dangerous as they may worsen hemodynamic status. Treatment should always be guided by continuous cardiac monitoring, frequent vital sign assessments, and serial evaluation of the patient's clinical status, with the goal of improving morbidity, mortality, and quality of life outcomes 1.

From the Research

Initial Management of Tachycardia due to Pulmonary Embolism (PE)

• The initial management of tachycardia due to pulmonary embolism (PE) involves assessing the clinical probability of PE and evaluating the patient's hemodynamic stability 2.
• In patients with a systolic blood pressure of at least 90 mm Hg, direct oral anticoagulants (DOACs) such as apixaban, edoxaban, rivaroxaban, or dabigatran are recommended as first-line therapy 2, 3.
• However, in patients with systolic blood pressure lower than 90 mm Hg, systemic thrombolysis is recommended and is associated with a reduced mortality rate 2.
• Tachycardia can be an ominous sign of right ventricular dysfunction and impending hemodynamic collapse, and should prompt aggressive therapy with vascular intervention 4.

Anticoagulation Therapy

• Anticoagulation is performed with unfractionated heparin (UFH) in hemodynamically unstable patients and with low molecular weight heparins (LMWH) or fondaparinux in normotensive patients 5.
• LMWH and fondaparinux are preferred over UFH in the initial anticoagulation of PE since they are associated with a lower risk of bleeding 5.
• All patients with PE require therapeutic anticoagulation for at least three months, and the decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 5.

Risk Stratification

• Patients with submassive PEs and sustained tachycardia in the setting of normal blood pressures should be recognized as being at high risk of impending hemodynamic collapse and should receive aggressive therapy with vascular intervention 4.
• The risk for recurrent PE after discontinuation of treatment is related to the features of the index PE event, and patients with strong persistent risk factors (such as active cancer) have a high risk of recurrence and should receive anticoagulant treatment of indefinite duration 5.