What is the treatment for pulmonary embolism?

Treatment of Pulmonary Embolism

Anticoagulation is the cornerstone of treatment for all patients with pulmonary embolism, with specific additional therapies determined by risk stratification. 1

Risk Stratification

• Patients should be categorized as high-risk (hemodynamically unstable), intermediate-risk, or low-risk based on hemodynamic stability, right ventricular function, and cardiac biomarkers 1
• High-risk PE is characterized by hemodynamic instability (hypotension, shock) 1, 2
• Intermediate-risk PE presents with hemodynamic stability but evidence of right ventricular dysfunction 1, 3
• Low-risk PE presents with hemodynamic stability and no evidence of right ventricular dysfunction 1, 3

Treatment Algorithm Based on Risk

High-Risk PE (Hemodynamically Unstable)

• Initiate unfractionated heparin (UFH) immediately with a weight-adjusted bolus injection 1, 2
• Administer systemic thrombolytic therapy without delay 1
• Consider norepinephrine and/or dobutamine for hemodynamic support 1, 2
• If thrombolysis is contraindicated or fails, surgical pulmonary embolectomy is recommended 1
• Percutaneous catheter-directed treatment should be considered if thrombolysis is contraindicated or fails 1, 2
• Extracorporeal membrane oxygenation (ECMO) may be considered in patients with refractory circulatory collapse or cardiac arrest 1

Intermediate or Low-Risk PE (Hemodynamically Stable)

• Initiate anticoagulation immediately without delay when clinical suspicion is high or intermediate 1, 3
• Low-molecular-weight heparin (LMWH) or fondaparinux is recommended over UFH for most patients 1
• For oral anticoagulation, non-vitamin K antagonist oral anticoagulants (NOACs) such as apixaban, dabigatran, edoxaban, or rivaroxaban are preferred over vitamin K antagonists (VKAs) 1, 4, 5
• When using VKAs, overlap with parenteral anticoagulation until an INR of 2.0-3.0 is reached 1
• Rescue thrombolytic therapy is recommended if hemodynamic deterioration occurs during anticoagulation treatment 1
• Surgical embolectomy or catheter-directed treatment should be considered as alternatives to rescue thrombolysis in patients with hemodynamic deterioration 1

Special Considerations

• NOACs are contraindicated in patients with severe renal impairment, during pregnancy and lactation, and in patients with antiphospholipid antibody syndrome 1, 3
• Inferior vena cava (IVC) filters should be considered in patients with acute PE and absolute contraindications to anticoagulation or in cases of PE recurrence despite therapeutic anticoagulation 1
• Routine use of IVC filters is not recommended 1
• Carefully selected patients with low-risk PE may be considered for early discharge and home treatment if proper outpatient care and anticoagulation can be provided 1

Duration of Anticoagulation

• All patients should receive therapeutic anticoagulation for at least 3 months 3, 6
• After 3 months, patients should be assessed for discontinuation of therapy, indefinite anticoagulation, or extended anticoagulation based on individual risk-benefit assessment 3, 6
• Patients with transient risk factors may discontinue anticoagulation after 3-6 months 3, 6
• Extended anticoagulation should be considered for patients with unprovoked PE and low bleeding risk 1, 3
• A reduced dose of apixaban or rivaroxaban should be considered after the first 6 months for extended therapy 1, 3

Follow-up Care

• Routine clinical evaluation is recommended 3-6 months after acute PE 1, 3
• Patients with persistent symptoms or mismatched perfusion defects beyond 3 months should be referred to a pulmonary hypertension expert center to exclude chronic thromboembolic pulmonary hypertension 1, 3

Common Pitfalls to Avoid

• Delaying anticoagulation while awaiting diagnostic confirmation in patients with high clinical probability 2, 3
• Using NOACs in patients with severe renal impairment or antiphospholipid antibody syndrome 1, 3
• Administering routine thrombolysis for intermediate or low-risk PE without hemodynamic compromise 1
• Losing patients to follow-up after initial treatment, risking missed chronic thromboembolic pulmonary hypertension diagnosis 1, 3