What is the treatment and management of pulmonary embolism (PE)?

Treatment and Management of Pulmonary Embolism (PE)

Direct oral anticoagulants (DOACs) such as apixaban or rivaroxaban are the first-line treatment for pulmonary embolism, with specific dosing regimens based on risk stratification and patient characteristics. 1

Initial Risk Stratification and Management

Risk stratification is essential for determining the appropriate treatment setting and intensity:

• Low-risk PE patients (PESI class I/II, sPESI 0, or meeting Hestia criteria) can be managed as outpatients if they don't have:

  • Hemodynamic instability
  • Need for thrombolysis or embolectomy
  • Severe pain requiring IV analgesia
  • High bleeding risk
  • Oxygen saturation <90%
  • Chronic kidney disease (CKD) stages 4-5 (eGFR <30 mL/min)
  • Severe liver disease
  • Heparin-induced thrombocytopenia (HIT)
  • Social barriers to outpatient care 2

• Intermediate-risk PE patients (PESI class III) require initial hospitalization but can be considered for early discharge when they meet low-risk criteria (PESI class I/II or sPESI 0) 2

• High-risk PE patients (hemodynamically unstable) require hospitalization, consideration of thrombolysis, and intensive monitoring 1

Anticoagulation Therapy

For Most Patients:

1. DOACs (preferred first-line):

   • Apixaban: 10 mg twice daily for 7 days, then 5 mg twice daily 1, 3
   • Rivaroxaban: 15 mg twice daily for 21 days, then 20 mg once daily 1, 4
   • Edoxaban: After initial LMWH for at least 5 days 1
   • Dabigatran: After initial LMWH for at least 5 days 2

2. Traditional Anticoagulation:

   • LMWH + Vitamin K Antagonist (VKA): LMWH initially, overlapping with VKA until INR is 2.0-3.0 for two consecutive days 1
   • Unfractionated Heparin (UFH): For patients with severe renal dysfunction (CrCl <30 mL/min) 1

Special Populations:

• Cancer-associated PE: LMWH recommended for at least 6 months 1
• Pregnancy: DOACs and VKAs are contraindicated; LMWH is the treatment of choice 2
• Severe renal dysfunction: UFH with careful monitoring; avoid rivaroxaban if CrCl <15 mL/min 1, 4

Advanced Interventions for High-Risk PE

• Systemic thrombolysis: Indicated for high-risk PE with cardiogenic shock and/or persistent hypotension; Alteplase 100 mg over 2 hours is the standard regimen 1

• Surgical embolectomy or catheter-directed intervention: Consider when thrombolysis is contraindicated or has failed 1

Duration of Anticoagulation

• Provoked PE (transient/reversible risk factors): 3 months 1
• Unprovoked PE or persistent risk factors: Extended (>3 months) 1
• Recurrent PE: Indefinite anticoagulation 1

Follow-up and Monitoring

• Clinical follow-up at 3-6 months after PE diagnosis 1
• Assess for:
  • Medication adherence
  • Bleeding complications
  • Signs of chronic thromboembolic pulmonary hypertension (CTEPH)
  • Need for extended anticoagulation 1

Important Precautions

• Avoid premature discontinuation of anticoagulants as it increases thrombotic risk 3, 4
• For planned procedures/surgery:
  • Stop apixaban at least 48 hours prior to procedures with moderate/high bleeding risk 3
  • Stop rivaroxaban at least 24 hours prior to procedures with low bleeding risk 4
• Monitor for signs of neurological impairment in patients receiving neuraxial anesthesia or undergoing spinal procedures 3, 4

Outpatient Management Pathway

For patients eligible for outpatient treatment:

1. Confirm low-risk status using validated tools (PESI/sPESI/Hestia)
2. Initiate DOAC (apixaban or rivaroxaban preferred for simplicity)
3. Arrange follow-up within 1-2 weeks
4. Provide clear instructions on warning signs requiring urgent medical attention 2, 1

Using a single DOAC in a treatment pathway is preferred to minimize potential confusion over dosing and administration 2.