What is the management approach for someone presenting with symptoms suggestive of pulmonary embolism (PE)?

From the Guidelines

The management of suspected pulmonary embolism (PE) should begin with prompt risk stratification and initiation of anticoagulation therapy as soon as possible, unless the patient is bleeding or has absolute contraindications, as recommended by the 2019 ESC guidelines 1. The approach to managing PE symptoms involves several key steps, including:

• Prompt risk stratification using validated tools like the Wells score or PERC rule
• Appropriate diagnostic testing, such as D-dimer testing and CT pulmonary angiography (CTPA)
• Initiation of anticoagulation therapy with either low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) like rivaroxaban or apixaban, as soon as possible, while the diagnostic workup is ongoing 1
• Consideration for thrombolytic therapy with alteplase or catheter-directed interventions in hemodynamically unstable patients
• Risk assessment for outpatient management using the PESI score or simplified PESI, with low-risk patients potentially managed as outpatients Some important considerations in the management of PE include:
• The use of recommended, validated diagnostic algorithms for PE, including standardized assessment of (pre-test) clinical probability and D-dimer testing 1
• The potential for false-positive findings in single subsegmental PE, and the need to discuss findings with the radiologist and/or seek a second opinion to avoid misdiagnosis 1
• The importance of further risk assessment involving clinical findings, evaluation of the size and/or function of the RV, and laboratory biomarkers as appropriate, in patients without haemodynamic instability 1
• The need for regular reassessment of bleeding risk and consideration of the benefits and risks of continuing anticoagulation therapy, with standard anticoagulation duration being 3-6 months for provoked PE and at least 6-12 months or indefinite for unprovoked PE 1

From the FDA Drug Label

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

The management approach for someone presenting with symptoms suggestive of pulmonary embolism (PE) is to consider treatment with rivaroxaban (XARELTO), as it is indicated for the treatment of PE.

• Key considerations include assessing the patient's renal function, as dosage adjustments may be necessary based on renal considerations.
• It is essential to follow the recommended dosage and administration guidelines, taking into account factors such as food/timing and renal function.
• The treatment should be initiated 6–10 hours after surgery once hemostasis has been established, if applicable.
• Patients with CrCl <15 mL/min should avoid using XARELTO. 2

From the Research

Management Approach for Pulmonary Embolism (PE) Symptoms

The management approach for someone presenting with symptoms suggestive of pulmonary embolism (PE) involves several steps:

• Assessment of the clinical probability of PE using a structured score or clinical gestalt 3
• D-dimer testing if indicated, with a level of less than 500 ng/mL associated with a posttest probability of PE less than 1.85% 3
• Chest imaging if indicated, with patients with a high probability of PE (>40% probability) undergoing chest imaging without the need for D-dimer testing 3
• First-line therapy consisting 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 3

Clinical Presentation of PE

The clinical presentation of PE can vary, but common symptoms include:

• Sudden onset dyspnea 4, 5
• Chest pain 4, 5
• Fainting or syncope 4
• Hemoptysis 4
• Atypical presentations such as shoulder and back pain 6

Diagnostic Considerations

Diagnosis of PE can be made using:

• Perfusion lung scan and pulmonary angiography 5
• Clinical procedures such as collection of clinical data through a standardized questionnaire and the use of findings from chest radiograph, ECG, and blood gas analysis 5
• Statistical techniques such as discriminant or logistic analysis to refine and improve the noninvasive diagnosis of PE 5

Treatment Options

Treatment options for PE include:

• Direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran 3
• Thrombolysis for patients with systolic blood pressure lower than 90 mm Hg 3
• Implantation of a vena cava filter (VCF) in patients with contraindication for anticoagulant therapy 7