What are the stepwise management options for pulmonary thromboembolism (PTE)?

Stepwise Management of Pulmonary Thromboembolism

Step 1: Immediate Risk Stratification and Initial Stabilization

Risk stratify all patients with suspected or confirmed PE based on hemodynamic stability to determine treatment intensity. 1

High-Risk PE (Hemodynamically Unstable)

• Defined by persistent hypotension (systolic BP <90 mmHg), cardiogenic shock, or cardiac arrest 1
• Administer systemic thrombolytic therapy immediately as first-line treatment 1
• Initiate supplemental oxygen for all patients with SaO2 <90%, escalating from conventional oxygen to high-flow nasal cannula, then non-invasive ventilation if needed 2
• Avoid aggressive fluid challenges as this worsens right ventricular failure 2
• Use vasopressors (dobutamine and/or norepinephrine) for hemodynamic support 2
• If thrombolysis is contraindicated or fails, perform surgical pulmonary embolectomy 1
• Catheter-directed embolectomy or fragmentation is an alternative when thrombolysis is absolutely contraindicated or has failed 1

Intermediate-Risk PE (Hemodynamically Stable with RV Dysfunction)

• Patients without shock but with evidence of RV dysfunction or myocardial injury 1
• Do not routinely administer systemic thrombolysis as primary treatment 1
• Administer rescue thrombolytic therapy only if hemodynamic deterioration occurs despite anticoagulation 1
• Consider measuring cardiac biomarkers (BNP, NT-proBNP, troponin) if RV dilatation identified on imaging; elevated biomarkers should prompt inpatient admission 1

Low-Risk PE (Hemodynamically Stable, No RV Dysfunction)

• PESI class I/II, sPESI 0, or meeting Hestia criteria 1
• Offer home treatment over hospital treatment where robust outpatient pathways exist 1
• Exclude patients with: HR >110 bpm, SBP <100 mmHg, oxygen saturation <90% on air, active bleeding risk, severe pain requiring opiates, CKD stage 4-5 (eGFR <30), inadequate home support, or other comorbidities requiring admission 1

Step 2: Initiate Anticoagulation

Begin anticoagulation immediately in all patients with suspected PE while awaiting diagnostic confirmation. 1

Parenteral Anticoagulation (Initial Phase)

• Prefer LMWH or fondaparinux over unfractionated heparin in hemodynamically stable patients 1
• Use unfractionated heparin only in high-risk PE or when rapid reversibility is needed 1
• LMWH dosing: weight-based, fixed therapeutic doses 1
• Fondaparinux: subcutaneous, weight-based dosing 1

Transition to Oral Anticoagulation

• Prefer a NOAC (apixaban, rivaroxaban, edoxaban, or dabigatran) over vitamin K antagonists for eligible patients 1
• NOACs contraindicated in: severe renal impairment (eGFR <30), antiphospholipid antibody syndrome, pregnancy/lactation 1
• If using VKA: overlap with parenteral anticoagulation until INR reaches 2.0-3.0 (target 2.5) 1
• Use INR range of 2.0-3.0, not lower ranges for patients on VKA 1

Step 3: Determine Duration of Anticoagulation

Administer therapeutic anticoagulation for minimum 3 months in all patients with PE. 1

Provoked PE (Transient Risk Factor)

• Discontinue anticoagulation after 3 months if first PE secondary to major transient/reversible risk factor (e.g., surgery, trauma, immobilization) 1

Unprovoked PE or Persistent Risk Factors

• Continue anticoagulation beyond 3 months, reassessing bleeding risk and patient preference 1
• Continue indefinitely for recurrent unprovoked VTE (at least one previous PE or DVT episode) 1

Special Populations

• Continue VKA indefinitely in antiphospholipid antibody syndrome (do not use NOACs) 1
• Pregnancy: use therapeutic fixed-dose LMWH based on early pregnancy weight; avoid NOACs 1

Step 4: Monitoring and Follow-Up

Routinely re-evaluate all patients 3-6 months after acute PE. 1

Reassessment Parameters

• Assess for persistent dyspnea, functional limitation, or new symptoms 1
• In patients on extended anticoagulation, reassess drug tolerance, adherence, hepatic/renal function, and bleeding risk at regular intervals 1

Screening for Chronic Complications

• Refer symptomatic patients with mismatched perfusion defects on V/Q scan beyond 3 months to pulmonary hypertension/CTEPH expert center 1
• Consider echocardiography, natriuretic peptides, and cardiopulmonary exercise testing in symptomatic patients 1

Critical Pitfalls to Avoid

• Never delay thrombolysis in high-risk PE while waiting for additional testing 1
• Never use aggressive fluid challenges in patients with RV dysfunction, as this worsens hemodynamics 2
• Never routinely insert inferior vena cava filters 1
• Never delay escalation of oxygen therapy when conventional supplementation proves insufficient 2
• Never overlook right-to-left shunting through patent foramen ovale as cause of refractory hypoxemia 2
• Never measure D-dimers in high clinical probability patients, as normal results do not safely exclude PE 1
• Never use NOACs in severe renal impairment or antiphospholipid antibody syndrome 1