What is the management of pulmonary embolism according to European Resuscitation Council (ERC) guidelines?

Management of Pulmonary Embolism According to European Guidelines

Risk Stratification Determines Treatment Pathway

The cornerstone of PE management is immediate risk stratification based on hemodynamic stability, which directly determines whether patients receive thrombolysis, standard anticoagulation, or early discharge. 1

High-Risk PE (Hemodynamically Unstable)

• High-risk PE is defined by systolic blood pressure <90 mmHg, cardiogenic shock, or persistent hypotension 1
• Perform bedside transthoracic echocardiography immediately to assess for right ventricular dysfunction 1
• If echocardiography shows RV dysfunction, proceed directly to treatment; if negative, obtain CTPA if immediately available and feasible 1

Immediate treatment for high-risk PE:

• Initiate unfractionated heparin (UFH) immediately with weight-adjusted bolus (80 U/kg) followed by continuous infusion (18 U/kg/h) without waiting for diagnostic confirmation 1, 2
• Systemic thrombolytic therapy is mandatory unless contraindicated (Class I recommendation) 1
• Administer vasopressor support with norepinephrine and/or dobutamine for hemodynamic stabilization 1
• Avoid aggressive fluid resuscitation as it worsens right ventricular failure 2
• If thrombolysis is contraindicated or fails, surgical pulmonary embolectomy is recommended (Class I) 1
• Percutaneous catheter-directed treatment should be considered as an alternative if thrombolysis fails 1
• ECMO may be considered in combination with surgical or catheter-directed treatment for refractory circulatory collapse or cardiac arrest 1

Intermediate-Risk PE (Hemodynamically Stable with RV Dysfunction)

For intermediate or low-risk PE, initiate anticoagulation without delay in patients with high or intermediate clinical probability while diagnostic workup is in progress (Class I recommendation) 1

Parenteral anticoagulation:

• LMWH or fondaparinux is recommended over UFH for most patients (Class I, Level A) 1
• This reflects superior pharmacokinetics, predictable dosing, and no need for monitoring 3, 4

Transition to oral anticoagulation:

• When starting oral anticoagulation, a NOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) is recommended in preference to vitamin K antagonists (Class I, Level A) 1
• Rivaroxaban: 15 mg twice daily for 3 weeks, then 20 mg once daily 2
• Apixaban: higher dose during first week, then maintenance dosing 2
• Dabigatran requires at least 5-10 days of parenteral anticoagulation before initiation 2
• When using VKAs, overlap with parenteral anticoagulation until INR reaches 2.5 (range 2.0-3.0) for at least 2 consecutive days 1

Critical contraindications to NOACs:

• NOACs are contraindicated in severe renal impairment, pregnancy and lactation, and antiphospholipid antibody syndrome (Class III) 1
• Use UFH in severe renal dysfunction (CrCl <30 mL/min) 2

Rescue therapy:

• Rescue thrombolytic therapy is recommended for patients with hemodynamic deterioration while on anticoagulation (Class I, Level B) 1
• Surgical embolectomy or catheter-directed treatment should be considered as alternatives to rescue thrombolysis 1
• Routine primary systemic thrombolysis is NOT recommended in intermediate or low-risk PE (Class III, Level B) 1

Low-Risk PE (Hemodynamically Stable without RV Dysfunction)

• Carefully selected low-risk PE patients should be considered for early discharge and home treatment if proper outpatient care and anticoagulant treatment can be provided (Class IIa, Level A) 1
• Use the same anticoagulation regimen as intermediate-risk PE 1

Special Populations and Considerations

Inferior Vena Cava Filters

• IVC filters should be considered in patients with acute PE and absolute contraindications to anticoagulation (Class IIa) 1
• IVC filters should be considered in cases of PE recurrence despite therapeutic anticoagulation (Class IIa) 1
• Routine use of IVC filters is NOT recommended (Class III, Level A) 1

Pregnancy

• Perform formal diagnostic assessment with validated methods if PE is suspected during pregnancy or postpartum 1
• Administer therapeutic fixed doses of LMWH based on early pregnancy weight in pregnant women without hemodynamic instability 1
• Do not use NOACs during pregnancy or lactation 1
• Do not insert spinal/epidural needle within 24 hours of last LMWH dose 1
• Do not administer LMWH within 4 hours of epidural catheter removal 1

Cancer Patients

• LMWH is the preferred initial and long-term treatment for cancer patients 2
• Dalteparin dosing: 200 IU/kg once daily for 1 month, then 150 IU/kg once daily for 5 months 2
• Apixaban is an effective alternative in cancer patients 2

Critical Pitfalls to Avoid

• Never delay anticoagulation while awaiting diagnostic confirmation in patients with high or intermediate clinical probability 2
• Do not stop parenteral anticoagulation before achieving therapeutic INR for 2 consecutive days when using VKAs 2
• Adjust UFH doses based on aPTT to maintain 1.5-2.5 times control value 2
• Routinely re-evaluate patients 3-6 months after acute PE 1
• Refer symptomatic patients with mismatched perfusion defects on V/Q scan beyond 3 months to a pulmonary hypertension/CTEPH expert center 1