What is the assessment for pulmonary embolism (PE)?

From the Guidelines

Pulmonary embolism assessment should begin with a systematic approach combining clinical evaluation, risk stratification, and appropriate diagnostic testing, as recommended by the 2019 ESC guidelines 1.

Key Steps in Assessment

• Evaluate the patient's vital signs, oxygen saturation, and symptoms such as dyspnea, chest pain, hemoptysis, or syncope.
• Calculate a clinical probability score using either the Wells criteria or Geneva score to determine if the patient is at low, intermediate, or high risk for PE.
• For patients with low or intermediate probability, order a D-dimer test; if negative, PE can generally be excluded.
• If D-dimer is positive or if the patient has high clinical probability, proceed with imaging studies, with computed tomographic pulmonary angiography (CTPA) being the gold standard diagnostic test, as noted in the guidelines 1.

Considerations for Diagnostic Testing

• Ventilation-perfusion (V/Q) scanning may be used in patients with contraindications to CTPA, such as renal failure or contrast allergy.
• Echocardiography can be useful for evaluating the severity of PE and guiding treatment decisions, especially in hemodynamically unstable patients 1.

Treatment Approach

• Hemodynamically unstable patients require immediate consideration for thrombolysis.
• Stable patients typically receive anticoagulation with either low molecular weight heparin, direct oral anticoagulants, or warfarin after initial parenteral anticoagulation, with the choice of anticoagulant depending on patient-specific factors and guidelines 1.

Risk Stratification and Outpatient Management

• Patients with confirmed PE should be risk-stratified using a validated clinical risk score, such as the Pulmonary Embolism Severity Index (PESI) or simplified PESI (sPESI) 1.
• Outpatient management of PE may be considered for patients at low risk, based on criteria such as PESI class I/II, sPESI 0, or meeting the Hestia criteria, with careful application of exclusion criteria 1.

From the FDA Drug Label

The primary efficacy endpoint was confirmed, symptomatic, recurrent VTE reported up to Day 97. The efficacy data are provided in Table 13. Table 13. Efficacy of Fondaparinux Sodium in the Treatment of Pulmonary Embolism (All Randomized) Endpoint Fondaparinux Sodium 5,7.5, or 10 mg SC once daily N = 1,103 Heparin aPTT adjusted IV N = 1,110 n% (95% CI)n% (95% CI) Total VTE a423.8% (2.8,5.1)565. 0% (3.8,6.5) DVT only121.1% (0.6,1.9)171.5% (0.9,2.4) Non-fatal PE141.3% (0.7,2.1)242.2% (1.4,3.2) Fatal PE161.5% (0.8,2.3)151.4% (0.8,2.2)

Pulmonary Embolism Assessment: Fondaparinux sodium is used for the treatment of acute symptomatic pulmonary embolism.

• The primary efficacy endpoint was confirmed, symptomatic, recurrent VTE reported up to Day 97.
• Non-fatal PE occurred in 1.3% of patients treated with fondaparinux sodium and 2.2% of patients treated with heparin.
• Fatal PE occurred in 1.5% of patients treated with fondaparinux sodium and 1.4% of patients treated with heparin 2.

From the Research

Pulmonary Embolism Assessment

• The assessment of pulmonary embolism involves evaluating the clinical probability of the condition using validated risk scores, such as the Wells score or the Geneva score 3.
• Patients with suspected pulmonary embolism should undergo diagnostic evaluation, including multidetector computed tomography (MDCT) or echocardiography, to confirm the presence of a pulmonary embolism 3.
• The diagnosis of pulmonary embolism can be challenging due to non-specific signs and symptoms, and a high index of suspicion is required to make an accurate diagnosis 4.
• Risk stratification of pulmonary embolism is crucial to determine the appropriate treatment approach, with patients classified as having high-risk, intermediate-risk, or low-risk pulmonary embolism 5, 3.

Treatment Options

• Anticoagulation is the mainstay of treatment for pulmonary embolism, with low-molecular-weight heparin (LMWH) or fondaparinux recommended as initial therapy for most patients 6, 5, 7, 3.
• Unfractionated heparin is generally recommended for patients with renal failure or those who are hemodynamically unstable 6, 3.
• Thrombolytic therapy may be considered for patients with massive pulmonary embolism or those with intermediate-risk pulmonary embolism who have evidence of right ventricular dysfunction 5, 7.
• Long-term oral anticoagulation with vitamin K antagonists, such as warfarin, is recommended for patients with pulmonary embolism, with a target International Normalized Ratio (INR) of 2.5 (range 2.0-3.0) 6.
• Direct oral anticoagulants, such as rivaroxaban and apixaban, have been shown to be effective and safe for the treatment of pulmonary embolism, and may be considered as an alternative to traditional anticoagulation therapy 5, 4.

Duration of Anticoagulation

• The duration of anticoagulation therapy for pulmonary embolism depends on the individual patient's risk of recurrence and bleeding 5.
• Patients with a first episode of pulmonary embolism secondary to a transient risk factor may be treated for at least 3 months, while those with idiopathic pulmonary embolism may require longer-term anticoagulation 6.
• Extended anticoagulation with direct oral anticoagulants may be beneficial for the prevention of recurrent venous thromboembolism, but the optimal duration of therapy is uncertain 5, 4.