What is the management approach for bilateral pulmonary embolism (PE)?

Management of Bilateral Pulmonary Embolism

Bilateral PE is managed identically to unilateral PE—the bilaterality itself does not change the treatment approach; instead, management is determined entirely by hemodynamic stability and risk stratification. 1

Immediate Risk Stratification

The first critical step is determining hemodynamic stability, which dictates all subsequent management decisions 1:

• High-risk (massive) PE: Systolic blood pressure <90 mmHg, cardiac arrest, or hemodynamic collapse requiring vasopressors 2, 1
• Intermediate-risk PE: Hemodynamically stable but with right ventricular dysfunction on imaging or elevated cardiac biomarkers 1
• Low-risk PE: Hemodynamically stable without RV dysfunction 1

Do not delay anticoagulation while awaiting diagnostic confirmation in patients with high clinical probability—this is a critical pitfall to avoid 1, 3.

Initial Anticoagulation Strategy

For Hemodynamically Unstable (High-Risk) PE

• Initiate unfractionated heparin intravenously immediately with an 80 units/kg bolus followed by continuous infusion 2, 1
• Administer systemic thrombolysis: 50 mg alteplase IV bolus if cardiac arrest is imminent, or 100 mg over 90 minutes if the patient is more stable 2, 1
• Consider surgical pulmonary embolectomy or catheter-directed interventions if thrombolysis is contraindicated or fails 1

For Hemodynamically Stable Patients

Direct oral anticoagulants (DOACs) are preferred over traditional LMWH-warfarin regimens 1, 3:

• Apixaban: 10 mg orally twice daily for 7 days, then 5 mg twice daily 4
• Alternatively: rivaroxaban, edoxaban, or dabigatran 1

If DOACs are contraindicated, use low molecular weight heparin (LMWH) or fondaparinux, overlapping with warfarin until INR reaches 2.0-3.0 2, 1

Critical contraindications to DOACs include: severe renal impairment (eGFR <30 mL/min), antiphospholipid syndrome, and end-stage renal disease on hemodialysis 1, 3

Determining Treatment Setting (Inpatient vs. Outpatient)

Low-risk patients may be considered for outpatient management if they meet specific criteria 2, 1:

Use validated risk scores (PESI class I/II, sPESI 0, or Hestia criteria) to identify low-risk candidates 2

Exclusion criteria mandating hospital admission 2:

• Heart rate >110 bpm or systolic BP <100 mmHg
• Oxygen saturation <90% on room air
• Active bleeding or high bleeding risk
• Severe pain requiring opiates
• Other medical comorbidities requiring admission
• CKD stage 4-5 (eGFR <30 mL/min) or severe liver disease
• Social factors (inability to return home, lack of support, compliance concerns)

Avoid aggressive fluid challenges in PE patients with RV dysfunction—this can worsen RV function 1

Supplemental Oxygen Management

• Administer supplemental oxygen to all patients with SaO₂ <90% 1
• For patients not responding to conventional oxygen, escalate to high-flow nasal cannula, then non-invasive ventilation if needed 1

Duration of Anticoagulation

All patients require at least 3 months of therapeutic anticoagulation 1, 3:

• Provoked PE (major transient/reversible risk factor): Discontinue after 3 months 1, 3
• Unprovoked PE or persistent risk factors: Consider indefinite anticoagulation 1
• After completing initial 6 months for DVT/PE: May reduce to apixaban 2.5 mg twice daily for extended prophylaxis against recurrence 4

Follow-Up Care

• Routinely re-evaluate patients at 3-6 months post-PE 1, 5
• Assess for persistent dyspnea or functional limitation that may indicate chronic thromboembolic pulmonary hypertension (CTEPH) 5

Key Clinical Pitfalls to Avoid

• Never delay anticoagulation in high-probability patients while awaiting imaging 1, 3
• Do not use DOACs in severe renal impairment (eGFR <30) or antiphospholipid syndrome 1, 3
• Avoid fluid boluses in patients with RV dysfunction—they worsen hemodynamics 1
• Do not use thrombolysis as first-line treatment in non-massive PE 2