Treatment of Pulmonary Embolism
The recommended treatment for pulmonary embolism is immediate anticoagulation with a preference for direct oral anticoagulants (DOACs) over vitamin K antagonists in eligible patients, with treatment strategy tailored according to risk stratification. 1, 2
Risk Stratification
Risk stratification is essential to determine the appropriate treatment approach:
- High-risk PE: Characterized by hemodynamic instability (hypotension, shock) 1, 3
- Intermediate-risk PE: Hemodynamically stable with right ventricular dysfunction and/or elevated cardiac biomarkers 2, 3
- Low-risk PE: Hemodynamically stable without evidence of right ventricular dysfunction or myocardial injury 2, 3
Initial Management
High-Risk PE (with hemodynamic instability)
- Initiate unfractionated heparin (UFH) immediately, including weight-adjusted bolus injection 1, 3
- Administer systemic thrombolytic therapy unless contraindicated 1, 3
- Consider surgical pulmonary embolectomy when thrombolysis is contraindicated or has failed 1
- Percutaneous catheter-directed treatment should be considered when thrombolysis is contraindicated or has failed 1
- Norepinephrine and/or dobutamine should be considered for hemodynamic support 1
- Extracorporeal membrane oxygenation (ECMO) may be considered in refractory circulatory collapse or cardiac arrest 1
Intermediate or Low-Risk PE
- Initiate anticoagulation without delay when clinical probability is high or intermediate, even while diagnostic workup is ongoing 1, 2
- For parenteral anticoagulation, low molecular weight heparin (LMWH) or fondaparinux is recommended over UFH for most patients 1, 2
- For oral anticoagulation, DOACs (apixaban, dabigatran, edoxaban, or rivaroxaban) are preferred over vitamin K antagonists (VKAs) in eligible patients 1, 2, 4
- When using VKAs, overlap with parenteral anticoagulation until INR reaches 2.0-3.0 1
- Rescue thrombolytic therapy should be administered if hemodynamic deterioration occurs during anticoagulation 1, 2
Special Considerations
- DOACs are contraindicated in patients with severe renal impairment, during pregnancy and lactation, and in patients with antiphospholipid antibody syndrome 1, 2, 4
- Inferior vena cava (IVC) filters should be considered only in patients with absolute contraindications to anticoagulation or recurrent PE despite therapeutic anticoagulation 1, 2
- Routine use of IVC filters is not recommended 1
- Selected low-risk PE patients may be considered for early discharge and home treatment if proper outpatient care and anticoagulation can be provided 1
Duration of Treatment
- Anticoagulation therapy should be administered for at least 3 months to all patients with PE 2
- After 3 months, patients should be assessed for discontinuation of therapy, indefinite anticoagulation, or extended anticoagulation based on individual risk-benefit assessment 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, 2, 4
- Routinely administering thrombolysis for intermediate or low-risk PE without hemodynamic compromise 1, 3
- Losing patients to follow-up after initial treatment, risking missed chronic thromboembolic pulmonary hypertension diagnosis 2
- Overlooking the need to reassess the risk-benefit ratio of continued anticoagulation after the initial treatment period 2