Pulmonary Embolism Management

Risk Stratification: The Critical First Step

All patients with suspected PE should be immediately risk-stratified based on hemodynamic stability, as this determines the entire treatment pathway and directly impacts mortality. 1, 2

High-Risk PE (Massive PE)

Defined by cardiogenic shock and/or persistent arterial hypotension (systolic BP <90 mmHg or drop ≥40 mmHg for >15 minutes) 3, 1
Characterized by collapse/hypotension with unexplained hypoxia, engorged neck veins, and often right ventricular gallop 3
Carries the highest early mortality risk and requires immediate aggressive intervention 3

Intermediate-Risk PE (Submassive PE)

Hemodynamically stable but with evidence of right ventricular dysfunction on imaging or elevated cardiac biomarkers (troponin, BNP/NT-proBNP) 3, 1
Represents a gray zone where treatment escalation may be needed if clinical deterioration occurs 2

Low-Risk PE

Hemodynamically stable without right ventricular dysfunction 1
PESI class I/II, sPESI 0, or meeting Hestia criteria 3
Candidates for outpatient management if no exclusion criteria present 3

Management Algorithm by Risk Category

HIGH-RISK PE: Immediate Life-Saving Interventions

Systemic thrombolysis is the first-line treatment for high-risk PE and should be administered immediately unless absolute contraindications exist. 3, 1, 2

Immediate Actions (within minutes):

Start IV unfractionated heparin immediately without waiting for confirmatory imaging—do not use LMWH or fondaparinux in this setting as they have not been tested in shock 3, 4
Administer oxygen to correct hypoxemia 3, 4
Correct systemic hypotension with vasopressors (norepinephrine, isoproterenol, or epinephrine preferred) 3, 5
Avoid aggressive fluid challenge—this worsens right ventricular failure; consider preload reduction or gentle diuresis instead 3, 5

Thrombolytic Therapy:

Alteplase 100 mg IV over 90 minutes (accelerated MI regimen) is the standard dose 3, 2
Alternative: Alteplase 50 mg IV bolus in cardiac arrest or rapidly deteriorating patients 3
Reassess at 30 minutes; dramatic hemodynamic improvement should occur 3
Resume unfractionated heparin 3 hours after thrombolysis completion, preferably weight-adjusted 3, 2
Contraindications to thrombolysis should be ignored in immediately life-threatening PE—the mortality benefit outweighs bleeding risk 3

When Thrombolysis Fails or is Contraindicated:

Surgical pulmonary embolectomy via median sternotomy with normothermic cardiopulmonary bypass is the recommended alternative 3, 2
Avoid aortic cross-clamping and cardioplegic arrest unless intracardiac thrombi or patent foramen ovale present 3
Catheter embolectomy or fragmentation may be considered when surgery unavailable, though evidence is limited 3

INTERMEDIATE-RISK PE: Anticoagulation with Selective Escalation

Immediate anticoagulation is mandatory, but routine thrombolysis is not recommended—reserve it only for clinical deterioration. 3, 1, 2

Initial Management:

Start LMWH or fondaparinux (preferred over unfractionated heparin in hemodynamically stable patients) 4, 2
Monitor closely for signs of deterioration (worsening hypoxemia, hypotension, rising troponin/BNP) 3
If RV dilatation identified on CT/echo with elevated biomarkers, consider inpatient admission for observation even if otherwise low-risk 3

Escalation Criteria:

Rescue thrombolysis if hemodynamic deterioration occurs during hospitalization 3, 2
One trial showed reduced need for emergency thrombolysis with upfront rtPA, but overall mortality was unchanged—thus routine use remains controversial 3

LOW-RISK PE: Anticoagulation ± Outpatient Management

Low-risk patients should be started on anticoagulation and considered for outpatient management where robust pathways exist. 3, 1

Outpatient Eligibility (must meet ALL criteria):

PESI class I/II, sPESI 0, or Hestia criteria met 3
Oxygen saturation ≥90% on room air 3
Heart rate <110 bpm, systolic BP ≥100 mmHg 3
No severe pain requiring opiates 3
No active bleeding risk, recent GI bleed/surgery, or uncontrolled hypertension 3
Not on full-dose anticoagulation at time of PE 3
eGFR ≥30 mL/min (CKD stages 1-3) 3
Adequate social support and ability to return for follow-up 3

Anticoagulation Strategy: The Foundation of All PE Treatment

Initial Anticoagulation (First 5-21 Days)

For hemodynamically stable patients, NOACs with single-drug approaches (rivaroxaban or apixaban) are preferred as they eliminate the need for parenteral bridging. 1, 2, 6

NOAC Regimens (Preferred):

Rivaroxaban: 15 mg PO twice daily with food for 21 days, then 20 mg once daily with food 2, 6
Apixaban: 10 mg PO twice daily for 7 days, then 5 mg twice daily 2
Edoxaban or dabigatran: Require 5 days of parenteral anticoagulation (LMWH/fondaparinux) before starting 1

Parenteral Options (when NOACs not suitable):

LMWH (weight-based dosing) or fondaparinux preferred over unfractionated heparin for stable patients 2, 7
Unfractionated heparin reserved for high-risk PE, severe renal impairment (CrCl <30 mL/min), or when rapid reversibility needed 3, 4

Warfarin (Alternative):

Target INR 2.5 (range 2.0-3.0) if NOACs contraindicated 2
Bridge with parenteral anticoagulation until INR therapeutic for 2 consecutive days 2

NOAC Contraindications:

Severe renal impairment (CrCl <15-30 mL/min depending on agent) 6
Antiphospholipid antibody syndrome (use warfarin) 1
Pregnancy/breastfeeding (use LMWH) 2
Mechanical heart valves 1

Duration of Anticoagulation

Minimum 3 months of anticoagulation is required for all PE, with extended therapy increasingly favored due to recurrence risk after cessation. 1, 2, 8

Decision Framework:

Provoked PE (surgery, trauma, estrogen, temporary risk factor): 3 months minimum 8
Unprovoked PE: Consider indefinite anticoagulation given high recurrence risk and safety of NOACs 8
Cancer-associated PE: Extended anticoagulation (often indefinite) 9
Recurrent VTE: Indefinite anticoagulation 1

Critical Caveat:

Premature discontinuation of anticoagulation dramatically increases thrombotic event risk—if stopping for any reason other than bleeding or completion of therapy, bridge with alternative anticoagulation. 6

Special Populations

Pregnancy:

Fixed-dose LMWH based on early pregnancy weight is treatment of choice 2
CTPA is safe (fetal radiation <50 mSv) and preferred over V/Q scan in first/second trimester 1
Avoid spinal/epidural procedures within 24 hours of last LMWH dose 2
Normal D-dimer has same exclusion value as non-pregnant patients 1

Severe Renal Impairment (CrCl <30 mL/min):

Avoid rivaroxaban if CrCl <15 mL/min 6
Consider dose-adjusted unfractionated heparin or warfarin 3

Cancer Patients:

LMWH traditionally preferred, though NOACs increasingly used 9
Extended/indefinite anticoagulation typically required 9

IVC Filters: Rarely Indicated

IVC filters should NOT be routinely used in PE patients. 1, 2

Consider only when:

Absolute contraindications to anticoagulation exist AND high VTE recurrence risk 1, 2
Recurrent PE despite therapeutic anticoagulation 2

Follow-Up and Long-Term Complications

All patients require routine re-evaluation at 3-6 months post-PE to assess for chronic thromboembolic pulmonary hypertension (CTEPH) and determine anticoagulation duration. 4, 1, 2

Follow-Up Protocol:

Implement integrated care model for hospital-to-ambulatory transition 4, 1
Assess for persistent dyspnea, exercise limitation, or signs of pulmonary hypertension 4
Refer to pulmonary hypertension/CTEPH expert center if persistent symptoms or mismatched perfusion defects on V/Q scan beyond 3 months 4, 1, 2

CTEPH Risk:

Rare but associated with significant morbidity and mortality 8
Early recognition and referral to specialized centers critical for optimal outcomes 4

Common Pitfalls to Avoid

Delaying anticoagulation while awaiting imaging—start immediately if clinical suspicion high 1, 2
Using LMWH/fondaparinux in high-risk PE—unfractionated heparin only in shock 3, 4
Aggressive fluid resuscitation in massive PE—worsens RV failure 3, 5
Withholding thrombolysis due to relative contraindications in life-threatening PE—mortality benefit outweighs bleeding risk 3
Routine IVC filter placement—not indicated in most cases 1, 2
Inadequate follow-up—CTEPH can be missed without systematic 3-6 month reassessment 4, 1

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