From the Guidelines
Pulmonary embolism (PE) management should prioritize anticoagulation therapy, with the most recent guidelines recommending initiation of anticoagulation without delay in patients with high or intermediate clinical probability of PE, while diagnostic workup is in progress 1. The management of PE involves several key components, including:
- Initiation of anticoagulation with low molecular weight heparin (LMWH) or fondaparinux, which is recommended over unfractionated heparin (UFH) for most patients 1
- Use of direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, or rivaroxaban, which are preferred over vitamin K antagonists (VKAs) for patients eligible for NOACs 1
- Overlapping parenteral anticoagulation with VKAs until an INR of 2.5 (range 2.0-3.0) is reached, for patients treated with VKAs 1
- Consideration of rescue thrombolytic therapy for patients with haemodynamic deterioration on anticoagulation treatment, or alternative treatments such as surgical embolectomy or percutaneous catheter-directed treatment 1 Key considerations in PE management include:
- High-risk PE patients, who should receive systemic thrombolytic therapy, surgical pulmonary embolectomy, or percutaneous catheter-directed treatment, depending on their specific clinical scenario 2
- Intermediate- or low-risk PE patients, who should receive anticoagulation therapy without delay, with a preference for LMWH or fondaparinux over UFH, and DOACs over VKAs 1
- Patients with contraindications to anticoagulation or recurrent PE despite adequate anticoagulation, who may require inferior vena cava filters or other alternative treatments 2, 3 Overall, the goal of PE management is to reduce the risk of recurrence and mortality, while minimizing the risk of anticoagulant-related bleeding complications. The most recent and highest quality study, the 2019 ESC guidelines, provides a comprehensive framework for PE management, emphasizing the importance of prompt anticoagulation and individualized treatment approaches 2, 1.
From the FDA Drug Label
HEPARIN SODIUM INJECTION is an anticoagulant indicated for • Prophylaxis and treatment of venous thrombosis and pulmonary embolism The guidelines for Pulmonary Embolism (PE) management include the use of heparin for prophylaxis and treatment of PE, as an anticoagulant.
- The use of heparin is indicated for both the prevention and treatment of PE. 4
From the Research
Guidelines for Pulmonary Embolism (PE) Management
- The initial treatment of patients with acute pulmonary embolism has traditionally involved unfractionated heparin, but low molecular weight heparins and direct oral anticoagulants are becoming more commonly used 5, 6, 7, 8.
- Unfractionated heparin is typically administered at a low fixed dose for prophylaxis in low to moderate risk patients, while high risk patients may require perioperative prophylaxis with low molecular weight heparins or oral anticoagulants 5, 9.
- Therapy for pulmonary embolism typically starts with an intravenous bolus dose of 5000 U heparin, followed by an infusion of 1250 U/h, with the dose adjusted to maintain a target aPTT value 5.
- Heparin is usually continued for 7-10 days, followed by oral anticoagulants for at least 3 months 5, 7.
- Direct oral anticoagulants are becoming the preferred choice for anticoagulation management in patients with PE, but may not be suitable for all patients, such as those with end-stage renal disease or obesity 6, 8.
- Low molecular weight heparins and unfractionated heparin may still be used in certain situations, such as in patients with renal failure or those who are breastfeeding 6, 7, 8.
- The objectives of treating patients with pulmonary embolism are to prevent death, reduce morbidity from the acute event, and prevent thromboembolic pulmonary hypertension, which can be achieved through the administration of heparin followed by oral anticoagulants 9.