What is the management for pulmonary embolism (PE) without right heart strain?

Management of Pulmonary Embolism Without Right Heart Strain

For pulmonary embolism without right heart strain (low-risk PE), anticoagulation alone is the recommended treatment, with NOACs (apixaban, rivaroxaban, edoxaban, or dabigatran) preferred over warfarin, and outpatient management should be strongly considered for appropriate patients. 1

Risk Stratification and Classification

Low-risk PE is defined as hemodynamically stable patients without evidence of right ventricular dysfunction or myocardial injury. 2 These patients should be risk-stratified using validated clinical scores:

• PESI class I/II, sPESI score of 0, or meeting Hestia criteria identify low-risk patients suitable for outpatient management. 1
• Thrombolytic therapy should NOT be used in low-risk PE (Class III recommendation). 2
• Measurement of RV:LV ratio on CT or echocardiographic assessment of RV function is not obligatory for identifying low-risk patients. 1

Anticoagulation Strategy

First-Line Treatment

NOACs are the recommended first-line anticoagulant for low-risk PE when patients are eligible. 1 The specific options include:

• Rivaroxaban 15 mg twice daily with food for 21 days, then 20 mg once daily with food 3
• Apixaban, edoxaban, or dabigatran per their respective dosing protocols 1
• NOACs are preferred over vitamin K antagonists due to ease of use and comparable efficacy/safety 1, 4

Alternative Anticoagulation

LMWH or fondaparinux is recommended for patients who cannot take NOACs (e.g., severe renal dysfunction with CrCl <15 mL/min, pregnancy). 1

• Unfractionated heparin should be reserved for patients at high bleeding risk or with severe renal dysfunction (CrCl <30 mL/min). 1
• Warfarin can be initiated at 5-10 mg depending on age and bleeding risk, overlapping with parenteral anticoagulation until INR is therapeutic. 1

Outpatient Management Criteria

Low-risk PE patients should be offered outpatient management where robust follow-up pathways exist. 1 Apply the following exclusion criteria before discharge:

Absolute Exclusions for Outpatient Management 1:

• Hemodynamic instability (HR >110 bpm, SBP <100 mmHg, need for inotropes/critical care)
• Oxygen saturation <90% on room air
• Active bleeding or high bleeding risk (recent GI bleed, surgery, prior intracranial bleeding, uncontrolled hypertension)
• Already on full-dose anticoagulation at time of PE
• Severe pain requiring opiates
• Other medical comorbidities requiring admission
• CKD stage 4-5 (eGFR <30 mL/min) or severe liver disease
• Heparin-induced thrombocytopenia within past year
• Social factors (inability to return home, inadequate home care, lack of communication, compliance concerns)

Additional Considerations

If RV dilatation is incidentally found on imaging in otherwise low-risk patients, measure cardiac biomarkers (BNP, NT-proBNP, troponin). 1 Normal values support outpatient management; elevated biomarkers should prompt inpatient admission for observation. 1

Duration of Anticoagulation

Anticoagulation should continue for at least 3 months for all PE patients. 5

Extended anticoagulation beyond 6 months should be considered for:

• Patients with unprovoked PE (no identifiable risk factor) 1
• Patients with persistent risk factors other than antiphospholipid syndrome 1
• Patients with minor transient/reversible risk factors 1

After the first 6 months, reduced-dose apixaban or rivaroxaban should be considered for extended therapy. 1

Follow-Up and Monitoring

Routine clinical evaluation is mandatory 3-6 months after acute PE. 1 This assessment should:

• Evaluate for persistent symptoms that might suggest chronic thromboembolic pulmonary hypertension (CTEPH) 1
• Ensure appropriate transition from hospital to ambulatory care through an integrated care model 1
• Refer symptomatic patients with mismatched perfusion defects on V/Q scan >3 months post-PE to a pulmonary hypertension/CTEPH expert center 1

Common Pitfalls to Avoid

Do not use thrombolysis in hemodynamically stable low-risk PE - the bleeding risks outweigh any potential benefits. 2 The meta-analysis data clearly shows no mortality benefit in non-massive PE (mortality 3.3% with thrombolysis vs 2.4% with heparin alone), while major bleeding increases significantly. 1

Do not delay anticoagulation while awaiting confirmatory testing if clinical probability is high or intermediate. 1 Anticoagulation should be initiated immediately in these scenarios. 1

Monitor platelet counts in patients receiving heparin to detect heparin-induced thrombocytopenia early, which occurs in 1-3% of patients on unfractionated heparin and ~1% on LMWH. 1