What is done to manage acute Pulmonary Embolism (PE)?

From the Guidelines

Management of acute pulmonary embolism (PE) should prioritize anticoagulation with unfractionated heparin (UFH), including a weight-adjusted bolus injection, to be initiated without delay in patients with high-risk PE, as recommended by the 2019 ESC guidelines 1.

Key Recommendations

• Anticoagulation with UFH is the primary treatment for high-risk PE, with a weight-adjusted bolus injection and continuous infusion adjusted to maintain aPTT at 1.5-2.5 times normal 1.
• Systemic thrombolytic therapy is recommended for high-risk PE, with alteplase 100 mg IV over 2 hours being a common regimen 1.
• Surgical pulmonary embolectomy is recommended for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed 1.
• Percutaneous catheter-directed treatment may be considered for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed 1.

Additional Considerations

• Supplemental oxygen should be provided to maintain oxygen saturation above 90% 1.
• Hemodynamic support with IV fluids or vasopressors may be necessary for patients with high-risk PE 1.
• Inferior vena cava filters are reserved for patients with contraindications to anticoagulation or recurrent PE despite adequate anticoagulation 1.
• Early ambulation is encouraged when the patient is stable to prevent complications of immobility 1.

Treatment Duration

• Treatment duration is typically 3-6 months for provoked PE and may be indefinite for unprovoked cases 1.
• Patients should be transitioned to oral anticoagulants like direct oral anticoagulants (DOACs) or warfarin after initial stabilization, with a target INR of 2-3 for warfarin 1.

From the FDA Drug Label

In a randomized, open-label, clinical trial in patients with a confirmed diagnosis of acute symptomatic PE, with or without DVT, fondaparinux sodium 5 mg (body weight <50 kg), 7.5 mg (body weight 50 to 100 kg), or 10 mg (body weight >100 kg) SC once daily (fondaparinux sodium treatment regimen) was compared to heparin intravenous bolus (5,000 USP units) followed by a continuous intravenous infusion adjusted to maintain 1.5 to 2.5 times aPTT control value. For both groups, treatment continued for at least 5 days with a treatment duration range 7 ± 2 days, and both treatment groups received vitamin K antagonist therapy initiated within 72 hours after the first study drug administration and continued for 90 ± 7 days, with regular dose adjustments to achieve an INR of 2 to 3

To manage acute Pulmonary Embolism (PE), the following treatments can be used:

• Fondaparinux sodium in doses of 5 mg, 7.5 mg, or 10 mg SC once daily, based on body weight
• Heparin intravenous bolus followed by a continuous intravenous infusion adjusted to maintain 1.5 to 2.5 times aPTT control value
• Vitamin K antagonist therapy initiated within 72 hours after the first study drug administration and continued for 90 ± 7 days, with regular dose adjustments to achieve an INR of 2 to 3 2

From the Research

Management of Acute Pulmonary Embolism (PE)

The management of acute PE involves several treatment options, including:

• Anticoagulant therapy with intravenous unfractionated heparin or subcutaneous low molecular weight heparin, followed by oral anticoagulant treatment for at least 3 months 3, 4, 5, 6
• Direct oral anticoagulants as the preferred choice of anticoagulation management 7
• Vitamin K antagonists and low-molecular-weight heparin as alternative options in special populations or selected patients 7
• Thrombolytic drugs, surgical embolectomy, or catheter-based embolectomy for patients with massive, life-threatening pulmonary embolism 4
• Inferior vena caval filter for patients with an absolute contraindication to, or a documented failure of, anticoagulant therapy 4

Anticoagulation Regimens

The anticoagulation regimens used in the management of acute PE include:

• Unfractionated heparin at a low fixed dose as the prophylactic regimen of choice for PE in patients undergoing general surgery or with serious medical diseases 3
• Low molecular weight heparins as a replacement for unfractionated heparin due to their more predictable pharmacodynamic and pharmacokinetic properties 4
• Oral anticoagulants, such as warfarin, with a target International Normalized Ratio (INR) of 2.5 (INR range: 2.0 to 3.0) 4

Treatment Duration

The duration of anticoagulation treatment for acute PE is:

• At least 3 months for patients with a first episode of pulmonary embolism secondary to a transient (reversible) risk factor 4, 5, 6
• Up to 6 to 12 months for patients with a first episode of idiopathic pulmonary embolism 4