What is the treatment for Pulmonary Embolism (PE)?

Treatment of Pulmonary Embolism

For hemodynamically stable PE, initiate a direct oral anticoagulant (DOAC) such as apixaban, rivaroxaban, edoxaban, or dabigatran immediately, as these are superior to traditional heparin-warfarin regimens with lower bleeding rates. 1, 2, 3

Initial Risk Stratification

• High-risk PE: Systolic blood pressure <90 mmHg indicates hemodynamic instability requiring immediate aggressive intervention 2
• Intermediate-risk PE: Hemodynamically stable but with evidence of right ventricular dysfunction on imaging or elevated cardiac biomarkers 2
• Low-risk PE: Hemodynamically stable without right ventricular dysfunction 2

Immediate Anticoagulation

For Hemodynamically Stable Patients (Most Common)

• Start a DOAC immediately while diagnostic workup proceeds, unless bleeding or absolute contraindications exist 1, 2, 4
• DOACs (apixaban, rivaroxaban, edoxaban, dabigatran) reduce bleeding by 0.6% absolute risk compared to warfarin and are noninferior for efficacy 3
• Do not delay anticoagulation while awaiting diagnostic confirmation in patients with high clinical probability 2, 4

Alternative Anticoagulation Options

• If DOACs are contraindicated, use low molecular weight heparin (LMWH) or fondaparinux over unfractionated heparin 1
• For vitamin K antagonist (VKA) transition: overlap parenteral anticoagulation until INR reaches 2.0-3.0 (target 2.5) 5, 1
• Unfractionated heparin: loading dose 5,000-10,000 units IV bolus, then 400-600 units/kg/day continuous infusion, adjusted to maintain aPTT 1.5-2.5 times control 5

For Hemodynamically Unstable Patients (High-Risk PE)

• Use intravenous unfractionated heparin for immediate anticoagulation 2
• Systemic thrombolysis is recommended and reduces mortality by 1.6% absolute risk (from 3.9% to 2.3%) 2, 3
• Thrombolytic options include:
  • rtPA: 0.6 mg/kg over 15 minutes (maximum 50 mg) or 100 mg over 2 hours 5
  • Streptokinase: 250,000 IU over 20-30 minutes, then 100,000 IU/hour for up to 24 hours 5
• Consider surgical pulmonary embolectomy or catheter-directed interventions when thrombolysis is contraindicated or has failed 2

Supportive Care

• Administer supplemental oxygen for SaO2 <90% 2
• Avoid aggressive fluid challenges in patients with right ventricular dysfunction as this can worsen hemodynamics 2
• If hypotension present, maintain central venous pressure at 15-20 mmHg to ensure maximal right heart filling 5
• Diuretics and vasodilators are not indicated 5

Duration of Anticoagulation

• Minimum 3 months of therapeutic anticoagulation for all PE patients 5, 1, 2
• Provoked PE (transient risk factor): Discontinue after 3 months 5, 2, 4
• First unprovoked PE: Consider indefinite anticoagulation if low bleeding risk 5
• Second unprovoked PE or active cancer: Indefinite anticoagulation recommended 5
• For cancer patients, consider LMWH (dalteparin 200 U/kg daily for 4-6 weeks, then 75% dose) for first 3-6 months 5

Special Populations to Avoid DOACs

• Antiphospholipid syndrome: DOACs are contraindicated; use VKA instead 2, 4
• Severe renal impairment (CrCl <30 mL/min): DOACs contraindicated 2, 4
• End-stage renal disease on hemodialysis: Use unfractionated heparin 4

Follow-Up Care

• Routinely re-evaluate patients at 3-6 months post-PE 1, 2
• Assess for persistent dyspnea or functional limitation 1, 2
• If symptoms persist, evaluate for chronic thromboembolic pulmonary hypertension (CTEPH) 1

Critical Pitfalls to Avoid

• Never delay anticoagulation in high-probability patients awaiting imaging confirmation 2, 4
• Do not use DOACs in severe renal impairment or antiphospholipid syndrome 2, 4
• Avoid aggressive fluid resuscitation in PE with right ventricular dysfunction 2
• Monitor platelet count if heparin continued beyond 5 days due to risk of heparin-induced thrombocytopenia 5
• Thrombolysis carries significant bleeding risk; reserve for hemodynamically unstable patients only 5