What is the treatment for pulmonary embolism?

Treatment of Pulmonary Embolism

The treatment of pulmonary embolism should begin with immediate anticoagulation, with the preferred agent being a non-vitamin K antagonist oral anticoagulant (NOAC) such as apixaban or rivaroxaban for most patients, while unfractionated heparin is recommended for hemodynamically unstable patients. 1

Initial Risk Stratification

Risk stratification is essential to guide appropriate treatment:

• Stratify patients with suspected or confirmed PE based on hemodynamic stability to identify those at high risk of early mortality 1, 2
• High-risk PE: Characterized by hemodynamic instability (hypotension, shock) 1, 2
• Intermediate-risk PE: Hemodynamically stable but with evidence of right ventricular dysfunction and/or myocardial injury 1
• Low-risk PE: Hemodynamically stable without evidence of right ventricular dysfunction 1

Treatment Based on Risk Stratification

High-Risk PE (with hemodynamic instability)

• Initiate unfractionated heparin (UFH) intravenously without delay, including a weight-adjusted bolus injection 1, 2
• Administer systemic thrombolytic therapy as first-line treatment 1
• Consider surgical pulmonary embolectomy for patients with contraindications to thrombolysis or when thrombolysis has failed 1
• Percutaneous catheter-directed treatment should be considered as an alternative when thrombolysis is contraindicated or has failed 1, 2
• Consider norepinephrine and/or dobutamine for patients with hypotension 1, 3
• Extracorporeal membrane oxygenation (ECMO) may be considered in combination with surgical embolectomy or catheter-directed treatment for patients with refractory circulatory collapse or cardiac arrest 1

Intermediate or Low-Risk PE

• Initiate anticoagulation without delay while diagnostic workup is in progress 1
• If parenteral anticoagulation is initiated, low-molecular-weight heparin (LMWH) or fondaparinux is recommended over UFH 1
• For patients eligible for NOACs (apixaban, dabigatran, edoxaban, or rivaroxaban), a NOAC is recommended in preference to a vitamin K antagonist (VKA) 1, 4, 5
• When using a VKA, overlap with parenteral anticoagulation until an INR of 2.5 (range 2.0-3.0) is reached 1
• Rescue thrombolytic therapy is recommended for patients who show hemodynamic deterioration while on anticoagulation treatment 1
• Routine use of primary systemic thrombolysis is not recommended for intermediate or low-risk PE 1

Anticoagulation Duration

• Administer therapeutic anticoagulation for at least 3 months to all patients with PE 1, 6
• Discontinue therapeutic oral anticoagulation after 3-6 months in patients with first PE secondary to a major transient/reversible risk factor 1, 6
• Consider indefinite anticoagulation for patients with:
  • Recurrent VTE not related to a major transient/reversible risk factor 1, 6
  • Unprovoked PE with low bleeding risk 1, 6
  • Antiphospholipid antibody syndrome (using VKA indefinitely) 1

Special Considerations

Inferior Vena Cava (IVC) Filters

• Consider IVC filters in patients with acute PE and absolute contraindications to anticoagulation 1
• Consider IVC filters in cases of PE recurrence despite therapeutic anticoagulation 1
• Routine use of IVC filters is not recommended 1

Early Discharge and Home Treatment

• Carefully selected patients with low-risk PE should be considered for early discharge and continuation of treatment at home if proper outpatient care and anticoagulant treatment can be provided 1

Contraindications to NOACs

• NOACs are not recommended in patients with severe renal impairment, during pregnancy and lactation, and in patients with antiphospholipid antibody syndrome 1

Follow-up Care

• Perform routine clinical evaluation 3-6 months after acute PE 1
• Implement an integrated model of care to ensure optimal transition from hospital to ambulatory care 1
• Refer symptomatic patients with mismatched perfusion defects on a V/Q scan >3 months after acute PE to a pulmonary hypertension/CTEPH expert center 1

Common Pitfalls to Avoid

• Delaying anticoagulation while awaiting diagnostic confirmation in patients with intermediate to high clinical probability of PE 1
• Using NOACs in patients with severe renal impairment, pregnancy, or antiphospholipid antibody syndrome 1
• Routine use of IVC filters when not indicated 1
• Failing to consider thrombolysis in high-risk PE patients 1, 3
• Administering aggressive fluid challenges in patients with right ventricular failure due to PE 2, 3