What is the treatment for pulmonary embolism?

Treatment of Pulmonary Embolism

Anticoagulation therapy is the cornerstone of treatment for pulmonary embolism (PE), with non-vitamin K antagonist oral anticoagulants (NOACs) recommended as first-line therapy for most patients with PE who are hemodynamically stable. 1

Risk Stratification

• PE should be stratified based on hemodynamic stability to guide treatment decisions 1, 2
• High-risk PE: Presents with shock or hypotension
• Intermediate-risk PE: Hemodynamically stable with right ventricular dysfunction
• Low-risk PE: Hemodynamically stable without right ventricular dysfunction

Initial Management

High-Risk PE (with shock or hypotension)

• Initiate unfractionated heparin (UFH) immediately with a weight-adjusted bolus followed by continuous infusion 1
• Administer systemic thrombolytic therapy unless contraindicated 1
• Provide oxygen to correct hypoxemia 1, 2
• Use vasopressors (norepinephrine and/or dobutamine) to correct hypotension 1
• If thrombolysis is contraindicated or fails, consider surgical pulmonary embolectomy 1
• Percutaneous catheter-directed treatment should be considered when thrombolysis is contraindicated or fails and surgical embolectomy is not immediately available 1
• Extracorporeal membrane oxygenation (ECMO) may be considered in patients with refractory circulatory collapse 1

Intermediate or Low-Risk PE

• Initiate anticoagulation without delay while diagnostic workup is in progress 1
• Low molecular weight heparin (LMWH) or fondaparinux is preferred over UFH for initial parenteral anticoagulation 1
• When starting oral anticoagulation, NOACs (apixaban, dabigatran, edoxaban, or rivaroxaban) are recommended over vitamin K antagonists (VKAs) 1, 3
• If using VKAs, overlap with parenteral anticoagulation until INR reaches 2.0-3.0 (target 2.5) 1
• Rescue thrombolytic therapy is recommended only if hemodynamic deterioration occurs 1
• Routine use of primary systemic thrombolysis is not recommended in hemodynamically stable patients 1

Anticoagulation Protocol

Initial Parenteral Anticoagulation

• UFH (for high-risk PE or severe renal impairment):
  • Initial bolus: 80 U/kg or 5,000-10,000 units 1
  • Continuous infusion: 18 U/kg/h, adjusted to maintain aPTT 1.5-2.5 times control 1
• LMWH or fondaparinux (for intermediate or low-risk PE):
  • Weight-adjusted dosing according to manufacturer's recommendations 1

Oral Anticoagulation

• NOACs (preferred option):
  • Rivaroxaban: 15 mg twice daily for 21 days, followed by 20 mg once daily 3
  • Other NOACs according to their specific dosing regimens 1, 4
• VKAs:
  • Target INR: 2.0-3.0 (target 2.5) 1
  • Overlap with parenteral anticoagulation until therapeutic INR is achieved 1

Duration of Anticoagulation

• Minimum 3 months for all patients with PE 5, 6
• For first PE with major transient/reversible risk factor: 3 months 5, 6
• For unprovoked PE or ongoing risk factors: consider extended therapy beyond 3 months 5, 6
• For recurrent PE not related to major transient risk factor: indefinite anticoagulation 5, 6

Special Considerations

Inferior Vena Cava (IVC) Filters

• Consider IVC filters in patients with:
  • Absolute contraindications to anticoagulation 1
  • PE recurrence despite therapeutic anticoagulation 1
• Routine use of IVC filters is not recommended 1

Early Discharge and Home Treatment

• Consider early discharge and home treatment for carefully selected low-risk PE patients 1
• Ensure proper outpatient care and anticoagulant treatment can be provided 1

Contraindications to NOACs

• NOACs are not recommended in patients with:
  • Severe renal impairment 1
  • Pregnancy and lactation 1
  • Antiphospholipid antibody syndrome 1

Follow-up Care

• Re-evaluate patients 3-6 months after acute PE 2, 5
• Assess for persistent symptoms or functional limitations 2, 5
• If symptoms persist, evaluate for chronic thromboembolic pulmonary hypertension (CTEPH) 2, 5