What is the treatment for someone diagnosed with Pulmonary Embolism (PE)?

Treatment of Pulmonary Embolism (PE)

The treatment for pulmonary embolism consists primarily of anticoagulation therapy, with Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) such as apixaban or rivaroxaban being the preferred first-line agents for most patients with PE. 1, 2

Initial Risk Stratification

• Risk stratify patients based on hemodynamic stability to determine appropriate treatment approach 1
• High-risk PE: Characterized by hemodynamic instability (systolic BP <90 mmHg) 3
• Intermediate-risk PE: Hemodynamically stable but with right ventricular dysfunction 3
• Low-risk PE: Hemodynamically stable without right ventricular dysfunction 1

Initial Anticoagulation

• Initiate anticoagulation as soon as possible while diagnostic workup is ongoing, unless bleeding or absolute contraindications exist 1
• For hemodynamically unstable patients (high-risk PE), use intravenous unfractionated heparin 3
• For hemodynamically stable patients, NOACs are preferred over traditional low molecular weight heparin (LMWH) followed by vitamin K antagonists (VKAs) 1, 4
• FDA-approved NOACs for PE treatment include:
  • Apixaban (indicated for treatment of PE) 5
  • Rivaroxaban (indicated for treatment of PE) 6

Reperfusion Strategies for High-Risk PE

• Systemic thrombolysis is recommended for patients with high-risk PE (hypotension) 3, 7
• Surgical pulmonary embolectomy should be considered when thrombolysis is contraindicated or has failed 8
• Catheter-directed interventions may be considered as alternatives to surgical treatment when thrombolysis is contraindicated or has failed 8
• Relative contraindications to thrombolysis include:
  • Recent surgery, trauma, or bleeding
  • Uncontrolled hypertension
  • Advanced liver disease
  • Pregnancy or recent postpartum 8

Management of Hypoxia

• Administer supplemental oxygen in all patients with PE and SaO2 <90% 3
• For patients not responding to conventional oxygen, consider high-flow nasal cannula followed by non-invasive ventilation if needed 3
• Invasive mechanical ventilation should be reserved for extreme instability, as positive pressure ventilation may worsen right ventricular failure 3
• Avoid aggressive fluid challenges in patients with right ventricular dysfunction 3

Duration of Anticoagulation

• All patients with PE require therapeutic anticoagulation for at least 3 months 1, 9
• For first PE secondary to a major transient/reversible risk factor, discontinue anticoagulation after 3 months 1, 10
• For unprovoked PE or persistent risk factors (e.g., active cancer), consider indefinite anticoagulation 1, 4
• Extended anticoagulation may be considered with reduced doses of apixaban or rivaroxaban after at least 6 months of therapeutic anticoagulation 4

Follow-up Care

• Routinely re-evaluate patients 3-6 months after acute PE 1, 10
• Assess for persisting or new-onset dyspnea or functional limitation 1
• If symptoms persist, implement diagnostic workup to exclude chronic thromboembolic pulmonary hypertension (CTEPH) 1, 9

Common Pitfalls to Avoid

• Delaying anticoagulation while awaiting diagnostic confirmation in patients with high clinical probability 10
• Using NOACs in patients with severe renal impairment or antiphospholipid syndrome 10
• Aggressive fluid challenges in PE patients with right ventricular dysfunction 3
• Failing to consider rescue thrombolysis in patients with worsening hypoxemia and hemodynamic deterioration despite anticoagulation 3