What is the management for bilateral pulmonary embolism?

From the Guidelines

Management of bilateral pulmonary embolism requires immediate anticoagulation therapy, typically starting with parenteral anticoagulants, and consideration of thrombolytic therapy in hemodynamically unstable patients, as recommended by the 2019 ESC guidelines 1 and further supported by the 2020 guidelines 1.

Key Considerations

• Anticoagulation therapy should be initiated without delay in patients with high-risk pulmonary embolism, using unfractionated heparin, low molecular weight heparin, or fondaparinux, as stated in the 2020 ESC guidelines 1.
• Systemic thrombolytic therapy is recommended for high-risk pulmonary embolism, with alteplase being a commonly used option 1.
• Surgical pulmonary embolectomy or percutaneous catheter-directed treatment may be considered in patients with high-risk pulmonary embolism who are contraindicated for or have failed thrombolysis 1.

Anticoagulation Regimens

• Parenteral anticoagulants such as unfractionated heparin (80 units/kg bolus followed by 18 units/kg/hr infusion), low molecular weight heparin (enoxaparin 1 mg/kg twice daily), or fondaparinux (5-10 mg daily based on weight) should be used initially.
• Oral anticoagulants like warfarin (target INR 2-3) or direct oral anticoagulants (DOACs) such as rivaroxaban, apixaban, or edoxaban should be overlapped with parenteral anticoagulants and continued long-term.

Additional Supportive Measures

• Oxygen supplementation should be provided to maintain saturation above 90% 1.
• Hemodynamic support with IV fluids and vasopressors may be necessary for hypotensive patients.
• Early ambulation is encouraged once the patient is stable.

Long-Term Management

• Anticoagulation should continue for at least 3 months for provoked pulmonary embolism and at least 6-12 months or indefinitely for unprovoked pulmonary embolism, as recommended by the 2019 ESC guidelines 1.
• Inferior vena cava filters are reserved for patients with contraindications to anticoagulation or recurrent pulmonary embolism despite adequate anticoagulation.

From the FDA Drug Label

• Prophylaxis and treatment of venous thrombosis and pulmonary embolism; The management for bilateral pulmonary embolism includes the use of heparin as an anticoagulant for prophylaxis and treatment of pulmonary embolism.

• The dosage of heparin should be adjusted according to the patient's coagulation test results, with the goal of achieving an activated partial thromboplastin time (aPTT) of 1.5 to 2 times normal.
• The recommended adult full-dose heparin regimens for therapeutic anticoagulant effect are outlined in Table 1, which includes dosing schedules for deep subcutaneous injection and intermittent intravenous injection 2.

From the Research

Management of Bilateral Pulmonary Embolism

The management of bilateral pulmonary embolism involves several key strategies to prevent death, reduce morbidity, and prevent thromboembolic pulmonary hypertension.

• Anticoagulation Therapy: The use of anticoagulant agents such as unfractionated heparin, low molecular weight heparins, and oral anticoagulants is crucial in the management of pulmonary embolism 3, 4, 5, 6. Unfractionated heparin is often the initial treatment of choice, given as an intravenous bolus followed by a maintenance dose, with the goal of preventing recurrent venous thromboembolism 6.
• Thrombolytic Therapy: Immediate thrombolysis is considered the standard of care for patients with significant hypoxemia or hypotension due to proven pulmonary embolism 3. Thrombolytic agents may also be useful in cases of massive pulmonary embolism, although more evaluation is needed 7.
• Supportive Care: Supportive care measures, such as oxygen therapy and fluid management, are also important in the management of pulmonary embolism. In hypotensive patients with right ventricular overload, fluid challenge may worsen the condition, and preload reduction or gentle diuresis may be necessary 3.
• Surgical Embolectomy: Surgical embolectomy is an option for unstable pulmonary embolism when there are absolute contraindications to thrombolysis or when thrombolytic therapy fails 3.
• Low Molecular Weight Heparins: Low molecular weight heparins have been shown to be effective in reducing venous thromboembolism and are often used as an alternative to unfractionated heparin 4, 5, 7. They have the advantage of fixed-dose administration and do not require monitoring of anticoagulation levels.

Treatment Objectives

The objectives of treating patients with pulmonary embolism are to:

• Prevent death
• Reduce morbidity from the acute event
• Prevent thromboembolic pulmonary hypertension These objectives are achieved through the administration of heparin followed by oral anticoagulants 4, 5.

Anticoagulant Agents

The choice of anticoagulant agent depends on the patient's risk factors and the severity of the pulmonary embolism. Unfractionated heparin, low molecular weight heparins, and oral anticoagulants are commonly used in the management of pulmonary embolism 3, 4, 5, 6, 7.