What is the recommended treatment for a patient diagnosed with pulmonary embolism?

Treatment of Pulmonary Embolism

The recommended treatment for pulmonary embolism is immediate anticoagulation, with low molecular weight heparin (LMWH) or fondaparinux preferred over unfractionated heparin (UFH) for most patients, followed by direct oral anticoagulants (DOACs) as the preferred long-term option over vitamin K antagonists for eligible patients. 1

Risk Stratification

Risk stratification is essential to determine the appropriate treatment approach:

• High-risk PE: Characterized by hemodynamic instability (hypotension, shock)

  • Requires immediate aggressive intervention 1, 2

• Intermediate-risk PE: Hemodynamically stable but with right ventricular dysfunction and/or elevated cardiac biomarkers

  • Requires close monitoring for potential deterioration 2, 3

• Low-risk PE: Hemodynamically stable without evidence of right ventricular dysfunction

  • May be eligible for early discharge and outpatient treatment in carefully selected cases 1

Acute Phase Treatment

High-Risk PE (with hemodynamic instability)

1. Immediate anticoagulation with UFH including weight-adjusted bolus injection 1, 3

2. Systemic thrombolytic therapy is recommended unless contraindicated 1, 3

3. If thrombolysis is contraindicated or fails:

   • Surgical pulmonary embolectomy 1
   • Percutaneous catheter-directed treatment should be considered 1, 3

4. Hemodynamic support:

   • Norepinephrine and/or dobutamine should be considered 1, 3
   • ECMO (extracorporeal membrane oxygenation) may be considered in refractory circulatory collapse or cardiac arrest 1

Intermediate or Low-Risk PE

1. Initiate anticoagulation without delay when clinical probability is high or intermediate, even while diagnostic workup is ongoing 1, 2

2. Parenteral anticoagulation:

   • LMWH or fondaparinux is recommended over UFH for most patients 1, 2
   • UFH should be considered in patients with severe renal impairment or if thrombolysis might be needed 2

3. Oral anticoagulation:

   • DOACs (apixaban, dabigatran, edoxaban, or rivaroxaban) are preferred over vitamin K antagonists (VKAs) for eligible patients 1, 2
   • If VKAs are used, overlap with parenteral anticoagulation until INR reaches 2.0-3.0 1

4. Rescue thrombolytic therapy is recommended only if hemodynamic deterioration occurs during anticoagulation 1, 3

Special Considerations

Contraindications to DOACs

DOACs are not recommended in patients with:

• Severe renal impairment 1, 4
• Pregnancy and lactation 1, 2
• Antiphospholipid antibody syndrome 1, 4

Inferior Vena Cava (IVC) Filters

• Consider IVC filters only in patients with:

  • Absolute contraindications to anticoagulation 1, 2
  • Recurrent PE despite adequate anticoagulation 1

• Routine use of IVC filters is not recommended 1

Duration of Treatment

• Minimum 3 months of therapeutic anticoagulation for all patients 2
• After 3 months, reassess for:
  • Discontinuation of therapy
  • Indefinite anticoagulation
  • Extended anticoagulation based on individual risk-benefit assessment 2

Follow-up Care

• Schedule follow-up examination after 3-6 months of anticoagulation 2
• Assess for:
  • Signs of venous thromboembolism recurrence
  • Bleeding complications
  • Persistent symptoms that may suggest chronic thromboembolic pulmonary hypertension 2

Common Pitfalls to Avoid

• Delaying anticoagulation while awaiting diagnostic confirmation in patients with high clinical probability 2, 5
• Using DOACs in patients with severe renal impairment or antiphospholipid antibody syndrome 1, 4
• Routine administration of 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
• Failure to achieve adequate anticoagulation during initial treatment, which is associated with increased risk of recurrent venous thromboembolism 6