From the Guidelines
The initial management of pulmonary embolism (PE) should focus on immediate anticoagulation with low molecular weight heparin (LMWH), unfractionated heparin, or direct oral anticoagulants (DOACs) to prevent further clot formation and reduce the risk of recurrent events. According to the 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism 1, LMWH is recommended as first-line therapy for patients with cancer and acute PE. For hemodynamically stable patients with confirmed or highly suspected PE, therapeutic anticoagulation can be initiated with either LMWH such as enoxaparin 1 mg/kg subcutaneously twice daily, unfractionated heparin as a bolus of 80 units/kg followed by continuous infusion at 18 units/kg/hour with aPTT monitoring, or DOACs like rivaroxaban 15 mg twice daily for 21 days followed by 20 mg daily.
The European Society of Cardiology (ESC) guidelines also recommend that anticoagulation should be initiated without delay in patients with high or intermediate clinical probability of PE while diagnostic workup is still ongoing 1. The guidelines suggest that the use of LMWH or fondaparinux is the recommended form of initial treatment for most patients with non-high-risk PE.
Key considerations in the initial management of PE include:
- Risk stratification using tools like PESI score or simplified PESI to determine the appropriate setting for treatment (outpatient vs. inpatient)
- Provision of supplemental oxygen to maintain oxygen saturation >90%
- Hemodynamic support with IV fluids and vasopressors for hypotensive patients
- Consideration of thrombolytic therapy with alteplase 100 mg IV over 2 hours or 50 mg over 15 minutes in cardiac arrest situations for hemodynamically unstable patients (systolic BP <90 mmHg or drop >40 mmHg) 1.
Overall, the goal of initial management is to stabilize the patient, prevent further clot formation, and reduce the risk of recurrent events, while also considering the patient's individual risk factors and clinical presentation.
From the Research
Initial Management of Pulmonary Embolism (PE)
The initial management of PE involves anticoagulation therapy to prevent further clot formation and reduce the risk of recurrence.
- The choice of anticoagulant depends on the patient's clinical presentation, renal function, and other comorbidities 2, 3.
- For hemodynamically stable patients, low molecular weight heparins (LMWHs) or direct oral anticoagulants (DOACs) are preferred over unfractionated heparin (UFH) due to their lower risk of bleeding 3, 4.
- DOACs, such as apixaban, edoxaban, rivaroxaban, or dabigatran, are non-inferior to traditional anticoagulation therapy with heparin and warfarin, and have a lower risk of bleeding 4.
- Systemic thrombolysis is recommended for patients with systolic blood pressure lower than 90 mm Hg, and is associated with a reduced mortality rate 4.
Anticoagulation Therapy
- Anticoagulation therapy should be initiated promptly in patients with a high or intermediate clinical probability of PE, while awaiting diagnostic test results 3.
- The duration of anticoagulation therapy depends on the individual patient's risk of recurrence and bleeding, and may be extended indefinitely in patients with a high risk of recurrence 3.
- The choice of anticoagulant may be influenced by factors such as renal function, liver function, and the presence of active cancer 3, 5.
Recent Advances in PE Management
- Recent studies have proposed diagnostic strategies to safely decrease imaging testing, and new modalities of catheter-based interventions have emerged for hemodynamically unstable PE patients 6.
- Direct oral anticoagulant treatment has become the new norm for normotensive PE patients, and a large proportion of patients are eligible for home treatment 6.
- Barriers and facilitators to guideline-concordant anticoagulation in patients hospitalized with acute PE have been identified, including agnosticism regarding choice of anticoagulant, inertia of learned practice, and institutional culture and support 5.