Treatment of Pulmonary Embolism
Anticoagulation therapy is the cornerstone of treatment for all patients diagnosed with pulmonary embolism, with the specific approach determined by risk stratification. 1
Risk Stratification
- Patients should be categorized as high-risk, intermediate-risk, or low-risk based on hemodynamic stability, right ventricular function, and cardiac biomarkers 2
- High-risk PE: Hemodynamically unstable (hypotension, shock)
- Intermediate-risk PE: Hemodynamically stable with right ventricular dysfunction
- Low-risk PE: Hemodynamically stable without right ventricular dysfunction 1
Initial Treatment
High-Risk PE (Hemodynamically Unstable)
- Initiate unfractionated heparin (UFH) immediately with weight-adjusted bolus injection 1
- Systemic thrombolytic therapy is recommended as first-line treatment 1
- If thrombolysis is contraindicated or fails, surgical pulmonary embolectomy is recommended 1
- Percutaneous catheter-directed treatment should be considered when thrombolysis is contraindicated or fails 1
- Vasopressor support with norepinephrine and/or dobutamine should be considered 1
- ECMO may be considered in patients with refractory circulatory collapse or cardiac arrest 1
Intermediate or Low-Risk PE (Hemodynamically Stable)
- Initiate anticoagulation immediately when clinical probability is high or intermediate, even while diagnostic workup is ongoing 1, 2
- For parenteral anticoagulation, LMWH or fondaparinux is preferred over UFH for most patients 1
- For oral anticoagulation, direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, or rivaroxaban are recommended over vitamin K antagonists (VKAs) in eligible patients 1, 3
- When using VKAs, overlap with parenteral anticoagulation until an INR of 2.0-3.0 is reached 1
- Rescue thrombolytic therapy should be administered if hemodynamic deterioration occurs during anticoagulation 1
- Routine use of primary systemic thrombolysis is not recommended for intermediate or low-risk PE 1, 4
Special Considerations
Contraindications to DOACs
- DOACs should not be used in patients with severe renal impairment, during pregnancy and lactation, or in patients with antiphospholipid antibody syndrome 1, 3
Inferior Vena Cava (IVC) Filters
- IVC filters should be considered only in patients with acute PE and absolute contraindications to anticoagulation 1
- IVC filters should be considered 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 low-risk PE patients should be considered for early discharge and home treatment if proper outpatient care and anticoagulation can be provided 1, 2
Duration of Treatment
- All patients should receive therapeutic anticoagulation for at least 3 months 2
- After 3 months, patients should be assessed for discontinuation of therapy, indefinite anticoagulation, or extended anticoagulation based on individual risk-benefit assessment 2
Follow-up Care
- Schedule follow-up examination after 3-6 months of anticoagulation to assess for signs of VTE recurrence, bleeding complications, and persistent symptoms 2
- If persistent symptoms are present, evaluate for chronic thromboembolic pulmonary hypertension 2
Common Pitfalls to Avoid
- Delaying anticoagulation while awaiting diagnostic confirmation in patients with high clinical probability 2
- Using DOACs in patients with severe renal impairment or antiphospholipid antibody syndrome 1
- Administering routine thrombolysis for hemodynamically stable patients 1, 4
- Failing to monitor for signs of hemodynamic deterioration during anticoagulation treatment 1
- Inserting IVC filters routinely without clear indications 1