What are the guidelines for Pulmonary Embolism (PE)?

From the Guidelines

The 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism recommend instituting anticoagulation therapy as soon as possible, while the diagnostic workup is ongoing, unless the patient is bleeding or has absolute contraindications 1. When managing patients with pulmonary embolism (PE), it is crucial to follow evidence-based guidelines to minimize morbidity, mortality, and improve quality of life. The guidelines emphasize the importance of early anticoagulation, even before a definitive diagnosis is made, if there is a high or intermediate clinical probability of PE 1.

Key Recommendations

• Institute anticoagulation therapy promptly, unless there are contraindications, to prevent further clot formation and reduce the risk of complications 1.
• Use recommended, validated diagnostic algorithms for PE, including standardized assessment of (pre-test) clinical probability and D-dimer testing 1.
• For patients without haemodynamic instability, confirmation of PE must be followed by further risk assessment involving clinical findings and comorbidity along with evaluation of the size and/or function of the RV, and with laboratory biomarkers if appropriate 1.
• Prefer anticoagulation with a NOAC over the LMWH–VKA regimen, unless the patient has contraindication(s) to NOACs 1.

Management Considerations

• In patients with haemodynamic instability, perform bedside transthoracic echocardiography as an immediate step to differentiate suspected high-risk PE from other acute life-threatening situations 1.
• For patients with intermediate–high-risk PE, reperfusion is not a first-line treatment, but a contingency plan should be in place in case the situation deteriorates 1.
• After acute PE, patients should not be lost to follow-up, and regular examinations should be conducted to check for possible signs of VTE recurrence, cancer, or bleeding complications of anticoagulation 1.

Anticoagulation Therapy

• The choice of anticoagulant should be based on the patient's clinical profile, with NOACs being preferred over traditional regimens in eligible patients 1.
• The decision to extend anticoagulation should be made on an individual basis, considering the benefits and risks, as well as the patient's preference 1.

By following these guidelines and recommendations, healthcare providers can optimize the management of patients with pulmonary embolism, reducing the risk of adverse outcomes and improving quality of life.

From the FDA Drug Label

1.3 Treatment of Pulmonary Embolism XARELTO is indicated for the treatment of pulmonary embolism (PE).

2.1 Recommended Dosage in Adults Table 1: Recommended Dosage in Adults IndicationRenal Considerations *DosageFood/Timing Treatment of DVT and/or PE 15 mg orally twice daily with food for the first 21 days followed by 20 mg orally once daily with food for the remaining treatment

The treatment guidelines for Pulmonary Embolism (PE) using rivaroxaban (XARELTO) are as follows:

• The recommended dosage is 15 mg orally twice daily with food for the first 21 days, followed by 20 mg orally once daily with food for the remaining treatment 2.
• It is essential to consider renal considerations and adjust the dosage accordingly, as patients with CrCl <15 mL/min should avoid use 2.
• The treatment of PE with XARELTO is indicated to reduce the risk of recurrent DVT and/or PE in adult patients at continued risk for recurrent DVT and/or PE after completion of initial treatment lasting at least 6 months 2.

From the Research

PE Guidelines Overview

• The management of pulmonary embolism (PE) involves anticoagulation as the cornerstone of therapy 3, 4, 5.
• The choice of anticoagulant agent, duration of treatment, and assessment of the risk-to-benefit ratio are crucial in PE management 3.

Anticoagulation Therapy

• Unfractionated heparin (UFH) is used in hemodynamically unstable patients, while low molecular weight heparins (LMWH) or fondaparinux are preferred in normotensive patients 3, 6.
• Non-vitamin K antagonist oral anticoagulants (NOACs) are recommended over vitamin K antagonists (VKAs) for eligible patients 3.
• Apixaban, Edoxaban, and Rivaroxaban are effective alternatives to LMWH in patients with active cancer 3.

Duration of Anticoagulation

• All patients with PE require therapeutic anticoagulation for at least three months 3.
• The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 3.
• Patients with a strong transient risk factor have a low risk of recurrence, while those with a strong persistent risk factor (such as active cancer) have a high risk of recurrence 3.

Management of Intermediate- and High-Risk PE

• Intermediate-risk (submassive) or high-risk (massive) PE patients have higher mortality than low-risk patients 4.
• Therapeutic approaches depend on a prompt, detailed evaluation, and PE response teams may help with rapid assessment and initiation of therapy 4.
• Catheter-directed therapies are emerging as an added approach to acute PE and have the potential to improve outcomes in PE 5.