What is the management of pulmonary embolism (PE) in a hospital setting?

Management of Pulmonary Embolism in Hospital Setting

Immediate anticoagulation with unfractionated heparin (UFH) should be initiated without delay in patients with high-risk PE, while diagnostic workup is ongoing, unless the patient is bleeding or has absolute contraindications. 1

Risk Stratification

Risk stratification is essential for determining appropriate management:

1. High-risk PE (massive PE): Hemodynamic instability (hypotension, shock)

   • Clinical indicators: collapse/hypotension, unexplained hypoxia, engorged neck veins, often right ventricular gallop 1

2. Intermediate-risk PE (submassive PE): Hemodynamically stable with right ventricular dysfunction and/or myocardial injury

3. Low-risk PE: Hemodynamically stable without right ventricular dysfunction or myocardial injury

Management Algorithm Based on Risk Stratification

High-Risk PE Management

• Immediate anticoagulation: Start UFH with weight-adjusted bolus injection (80 units/kg IV) 1
• Systemic thrombolysis: Recommended first-line reperfusion therapy (Class I recommendation) 1
  • Alteplase: 100 mg over 90 minutes for stable patients with confirmed massive PE 1
  • For cardiac arrest: 50 mg IV alteplase bolus 1
• Surgical pulmonary embolectomy: Recommended when thrombolysis is contraindicated or has failed (Class I recommendation) 1
• Catheter-directed treatment: Consider when thrombolysis is contraindicated or has failed (Class IIa recommendation) 1
• Hemodynamic support: Consider norepinephrine and/or dobutamine (Class IIa recommendation) 1
• ECMO: May be considered in combination with surgical embolectomy or catheter-directed treatment for patients with refractory circulatory collapse or cardiac arrest (Class IIb recommendation) 1

Intermediate-Risk PE Management

• Anticoagulation: Standard treatment
• Close monitoring: For signs of hemodynamic deterioration
• Reperfusion therapy: Not first-line treatment but should have a contingency plan if deterioration occurs 1

Low-Risk PE Management

• Anticoagulation: Standard treatment
• Consider outpatient treatment if:
  • Patient is not unduly breathless
  • No medical or social contraindications
  • Efficient protocol in place 1

Anticoagulation Options

Initial Anticoagulation

• UFH: Initial IV bolus of 5,000-10,000 IU, followed by continuous IV infusion of 1,300 IU/hour, target aPTT 1.5-2.5 times control 2
• LMWH: Preferred over UFH for most patients with acute PE due to comparable efficacy, lower risk of major bleeding, and more predictable pharmacokinetics 2

Long-term Anticoagulation

• Direct Oral Anticoagulants (DOACs): Preferred over vitamin K antagonists (VKAs) unless contraindicated 1, 2
  • Rivaroxaban: 15 mg twice daily for 21 days, followed by 20 mg once daily 2, 3
  • Apixaban: 10 mg twice daily for 7 days, followed by 5 mg twice daily 2, 4
  • Dabigatran: 150 mg twice daily after initial LMWH 2
  • Edoxaban: 60 mg once daily (30 mg once daily if CrCl 30-50 mL/min or body weight <60 kg) 2

Duration of Anticoagulation

• Secondary PE due to transient/reversible risk factors: 3 months
• Unprovoked PE or persistent risk factors: Extended (>3 months)
• Recurrent PE: Indefinite 2

Special Considerations

Vena Cava Filters

• Indications: VTE with absolute contraindication to anticoagulation, recurrent PE despite adequate anticoagulation 1
• Caution: Associated with increased risk of recurrent DVT 2, 5

Multidisciplinary Approach

• Pulmonary Embolism Response Team (PERT): Recommended for management of high-risk and selected intermediate-risk PE cases 1, 6
• Team composition: Specialists from cardiology, pulmonology, hematology, vascular medicine, anesthesiology/intensive care, cardiothoracic surgery, and interventional radiology 1

Follow-up Care

• Regular clinical evaluation: Recommended at 3-6 months after acute PE 2
• Monitor for:
  • Medication adherence
  • Bleeding complications
  • Signs of chronic thromboembolic pulmonary hypertension (CTEPH)
  • Need for extended anticoagulation 2

Important Pitfalls to Avoid

• Delaying anticoagulation: Start anticoagulation while diagnostic workup is ongoing unless contraindicated 1
• Inappropriate risk stratification: Ensure proper assessment to guide treatment decisions
• Premature discontinuation of anticoagulation: Increases risk of recurrent thrombotic events 3, 4
• Overlooking contraindications to thrombolysis: Assess bleeding risk carefully before administering thrombolytics
• Missing CTEPH diagnosis: Follow up patients with persistent symptoms after PE treatment 1, 2

Remember that management decisions should be guided by risk stratification, and high-risk patients require immediate intervention to reduce mortality and improve outcomes.