What is the management of acute pulmonary embolism?

Management of Acute Pulmonary Embolism

The management of acute pulmonary embolism should be stratified based on risk assessment, with high-risk PE requiring immediate thrombolysis, intermediate-risk PE requiring anticoagulation with close monitoring, and low-risk PE treated with direct oral anticoagulants as first-line therapy. 1

Risk Stratification

Risk stratification is essential for determining the appropriate treatment approach:

1. High-risk PE (hemodynamically unstable with shock/hypotension)
2. Intermediate-risk PE (hemodynamically stable with right ventricular dysfunction and/or myocardial injury)
3. Low-risk PE (hemodynamically stable without RV dysfunction)

Initial Management

High-Risk PE (with shock or hypotension)

• Anticoagulation: Initiate unfractionated heparin without delay 2

  • IV bolus of 80 U/kg followed by infusion at 18 U/kg/h
  • Adjust dose based on aPTT (target 1.5-2.5 times control)

• Hemodynamic support:

  • Correct systemic hypotension to prevent RV failure progression 2
  • Vasopressive drugs for hypotensive patients 2
  • Dobutamine/dopamine for low cardiac output with normal blood pressure 2
  • Avoid aggressive fluid challenge 2
  • Administer oxygen for hypoxemia 2

• Thrombolytic therapy:

  • Recommended for patients with cardiogenic shock/persistent arterial hypotension 2
  • Standard regimen: alteplase 100 mg over 2 hours 1

• When thrombolysis is contraindicated or fails:

  • Surgical pulmonary embolectomy via median sternotomy 2
  • Catheter-directed interventions (thrombus fragmentation, rheolytic thrombectomy) as alternative when surgical options unavailable 1

Intermediate-Risk PE (hemodynamically stable with RV dysfunction)

• Anticoagulation: Primary treatment approach 1

  • Non-vitamin K antagonist oral anticoagulants (NOACs) preferred as first-line therapy 1
  • Low molecular weight heparin (LMWH) or fondaparinux as initial treatment 2
  • Close monitoring for clinical deterioration

• Thrombolysis:

  • Routine use not recommended 2
  • May be considered in selected patients with intermediate-risk PE 2
  • Monitor for signs of hemodynamic decompensation

Low-Risk PE (hemodynamically stable without RV dysfunction)

• Anticoagulation:
  • NOACs (apixaban, rivaroxaban, edoxaban, dabigatran) preferred 1
  • LMWH or fondaparinux as initial treatment if NOACs not immediately available 2
  • Thrombolytic therapy should not be used 2

Anticoagulation Therapy Details

Initial Anticoagulation

• NOACs (preferred): Apixaban, rivaroxaban, edoxaban, or dabigatran 1
• LMWH (e.g., enoxaparin): 1 mg/kg twice daily subcutaneously 3
• Fondaparinux: Weight-based dosing
• Unfractionated heparin: Reserved for patients with severe renal impairment (CrCl <30 mL/min) or high bleeding risk 2

Duration of Anticoagulation

• Minimum 3 months for all patients 1

• Consider extended/indefinite anticoagulation for:

  • Recurrent PE not related to transient risk factors
  • Unprovoked PE
  • Persistent risk factors
  • Antiphospholipid syndrome 1

• After 6 months of extended anticoagulation, reduced doses of apixaban or rivaroxaban may be considered 1

Special Populations

Cancer Patients

• Edoxaban or rivaroxaban should be considered as alternatives to LMWH, except in patients with gastrointestinal cancer 1

Pregnancy

• NOACs not recommended during pregnancy or lactation 1
• LMWH is the anticoagulant of choice
• Thrombolysis or surgical embolectomy should be considered for pregnant women with high-risk PE 1

Renal Impairment

• For severe renal impairment (CrCl <30 mL/min), use unfractionated heparin with aPTT monitoring 2
• Avoid rivaroxaban in patients with CrCl <15 mL/min 4

Contraindications to Anticoagulation

When anticoagulation is contraindicated (e.g., active major bleeding, recent intracranial hemorrhage):

• Consider inferior vena cava filter placement as a temporary measure 5
• Resume anticoagulation as soon as contraindication resolves

Follow-up

• Routine clinical evaluation 3-6 months after acute PE 1
• Assessment should include:
  • Persistent symptoms
  • Medication adherence
  • Complications
  • Need for extended anticoagulation
• Refer to specialized center for chronic thromboembolic pulmonary hypertension (CTEPH) evaluation if persistent symptoms and perfusion defects 1

Common Pitfalls and Caveats

• Avoid delaying anticoagulation while awaiting diagnostic confirmation in patients with high clinical suspicion 2
• Do not initiate NOACs in hemodynamically unstable patients with PE 4
• Avoid routine thrombolysis in non-high-risk PE patients 2
• Do not use NOACs in patients with triple-positive antiphospholipid syndrome due to increased risk of recurrent thrombosis 4
• Avoid NOACs in patients with mechanical heart valves 4
• Monitor closely for bleeding complications, especially in elderly patients, those with renal impairment, or low body weight 3, 4