What are the guidelines for managing pulmonary embolism (PE) in high-risk patients, including those undergoing major surgery or with impaired renal function?

Guidelines for Pulmonary Embolism Management (ATS/ERS)

Risk Stratification Framework

All patients with suspected or confirmed PE must be stratified based on hemodynamic stability to identify those at high risk of early mortality. 1

High-Risk PE

• Defined by hemodynamic instability with systolic blood pressure <90 mm Hg or cardiogenic shock 1, 2
• Requires immediate bedside echocardiography or emergency CTPA depending on availability 1

Intermediate-Risk PE

• Characterized by right ventricular dysfunction and/or myocardial injury but WITHOUT hemodynamic instability 2
• Further stratification into intermediate-high and intermediate-low risk categories guides management 1

Low-Risk PE

• Hemodynamically stable without evidence of right ventricular dysfunction or myocardial injury 2
• Candidates for early discharge and home treatment 3

Acute Phase Management (First 5-10 Days)

High-Risk PE Treatment

Initiate intravenous unfractionated heparin with a weight-adjusted bolus immediately without waiting for diagnostic confirmation in suspected high-risk PE. 1, 3

• Systemic thrombolytic therapy is the definitive treatment for high-risk PE presenting with cardiogenic shock and/or persistent arterial hypotension (Class I recommendation). 1, 2

• Vasopressor support with norepinephrine and/or dobutamine should be considered for hemodynamic support 1, 3

• Aggressive fluid challenge is NOT recommended as it may worsen right ventricular failure 1

When Thrombolysis Fails or is Contraindicated

Surgical pulmonary embolectomy is recommended (Class I) for high-risk PE patients when thrombolysis is contraindicated or has failed. 1, 2

• Catheter-directed therapy (embolectomy or fragmentation) should be considered as an alternative (Class IIa recommendation) 2, 3

• Consider involving a Pulmonary Embolism Response Team (PERT) for complex cases 2

Absolute Contraindications to Thrombolysis

• History of hemorrhagic stroke or stroke of unknown origin 2
• Ischemic stroke within previous 6 months 2
• Central nervous system neoplasm 2
• Major trauma, surgery, or head injury within previous 3 weeks 2
• Active bleeding 2

Non-High-Risk PE Treatment

For hemodynamically stable patients, prefer low molecular weight heparin (LMWH) or fondaparinux over unfractionated heparin for initial anticoagulation. 1

• Routine use of thrombolysis in intermediate-risk or low-risk PE is NOT recommended (Class III). 1, 2

• The exception: thrombolysis may be considered in highly selected intermediate-risk patients, though this remains controversial 1

• Unfractionated heparin with aPTT target of 1.5-2.5 times normal is recommended for patients at high bleeding risk or with severe renal dysfunction 1

Oral Anticoagulation Phase (Maintenance)

When initiating oral anticoagulation in PE patients eligible for a direct oral anticoagulant (DOAC), prefer a DOAC over vitamin K antagonists. 1, 3

DOAC Dosing

• Apixaban and rivaroxaban use higher doses during the first 1 and 3 weeks respectively 3
• Options include apixaban, dabigatran, edoxaban, or rivaroxaban 1, 4

VKA Alternative

• When using vitamin K antagonists, overlap with parenteral anticoagulation until INR reaches 2.5 (range 2.0-3.0) for at least 2 consecutive days 1, 3
• Continue parenteral anticoagulation for at least 5 days before transitioning 1

DOAC Contraindications

Do NOT use DOACs in patients with severe renal impairment, during pregnancy and lactation, or in patients with antiphospholipid antibody syndrome. 1, 3, 4

Duration of Anticoagulation (Extended Phase)

Discontinue oral anticoagulation after 3 months in patients with first PE secondary to a major transient/reversible risk factor. 1, 3

Continue oral anticoagulation indefinitely in patients with recurrent VTE (at least one previous episode) not related to a major transient or reversible risk factor. 1, 3

• For patients with antiphospholipid antibody syndrome, continue VKA (not DOAC) indefinitely 1, 3

• For cancer-associated PE, at least 6 months of LMWH is recommended, followed by LMWH or VKA as long as cancer is active 1

• Reassess drug tolerance, adherence, hepatic and renal function, and bleeding risk at regular intervals in patients on extended anticoagulation 1

Special Considerations

Inferior Vena Cava Filters

Routine use of IVC filters is NOT recommended. 1, 3

• Consider IVC filters only in patients with acute PE and absolute contraindications to anticoagulation 3
• May be considered for recurrent PE despite therapeutic anticoagulation 3

Renal Impairment

• In severe renal dysfunction, use unfractionated heparin instead of LMWH or fondaparinux 1
• DOACs are contraindicated in severe renal impairment 1, 4

Pregnancy

Perform formal diagnostic assessment with validated methods if PE is suspected during pregnancy or postpartum. 1

• DOACs are contraindicated; use LMWH or unfractionated heparin 1, 3

Critical Pitfalls to Avoid

• Never use thrombolysis in hemodynamically stable low-risk PE patients - this increases bleeding risk without mortality benefit 1, 2

• Do not measure D-dimers in high clinical probability patients - normal results do not safely exclude PE 1

• Avoid rivaroxaban and other DOACs in hemodynamically unstable PE requiring thrombolysis or embolectomy 4

• Do not perform CT venography as adjunct to CTPA - it adds no diagnostic value 1