From the Guidelines
The treatment plan for pulmonary embolism involves immediate anticoagulation and, in high-risk cases, systemic thrombolytic therapy or surgical pulmonary embolectomy.
Treatment Overview
- Anticoagulation: Initiate anticoagulation with unfractionated heparin (UFH) as soon as possible in patients with high-risk pulmonary embolism (PE), as recommended by 1 and 1.
- Systemic Thrombolytic Therapy: Administer systemic thrombolytic therapy to patients with high-risk PE, as suggested by 1, 1, and 1.
- Surgical Pulmonary Embolectomy: Consider surgical pulmonary embolectomy for patients with high-risk PE in whom thrombolysis is contraindicated or has failed, as recommended by 1, 1, and 1.
Specific Treatment Recommendations
- For patients with high-risk PE, intravenous UFH should be administered as the preferred mode of initial anticoagulation, as stated in 1.
- LMWH or fondaparinux may be preferred over UFH in patients without haemodynamic instability, as suggested by 1.
- NOACs are preferred over the LMWH-VKA regimen for anticoagulation unless contraindicated, as recommended by 1.
Additional Considerations
- Bed rest has no beneficial effect on the clinical outcome of patients with high-risk PE, as noted in 1.
- Follow-up is crucial after acute PE to monitor for signs of VTE recurrence, cancer, or bleeding complications, and to detect/treat comorbidity or chronic thrombo-embolic disease, as emphasized in 1.
From the Research
Treatment Plan for Pulmonary Embolism
The treatment plan for pulmonary embolism involves several steps, including:
- Anticoagulation therapy, which should be initiated as early as possible in patients with a high clinical probability of pulmonary embolism 2, 3, 4
- Risk stratification of early mortality to determine the severity of the pulmonary embolism and guide treatment decisions 5, 4, 6
- Evaluation of the clinical severity of the pulmonary embolism to determine whether the patient will benefit from thrombolysis or not 2
- Consideration of the patient's renal function, diagnosis of active cancer, calculated bleeding risk, and estimated patient compliance to guide anticoagulant agent selection 2
Anticoagulation Therapy
Anticoagulation therapy is a crucial component of the treatment plan for pulmonary embolism, with options including:
- Parenteral administration of heparin, low-molecular-weight heparin, or fondaparinux overlapped and followed by oral vitamin K antagonists 3
- Direct oral anticoagulants, such as rivaroxaban and apixaban, which have demonstrated non-inferiority to standard therapy and provided significant reductions in major bleeding rates 4
- Warfarin anticoagulation, which continues to be a well-known, valid, and cost-effective treatment option 2
Reperfusion Strategy
A reperfusion strategy should be considered in patients with high-risk pulmonary embolism, defined as pulmonary embolism with clinical hemodynamic instability, and may include:
- Thrombolytic therapy 6
- Surgical or percutaneous embolectomy, which is an alternative in case of contraindication to thrombolytic therapy 6
Patient Management
Patient management should be guided by the severity of the pulmonary embolism, with:
- High-risk patients requiring hospitalization and continuous care monitoring 6
- Intermediate-risk patients warranting hospitalization and continuous care monitoring for patients presenting with elevated biomarkers and right ventricular dysfunction 6
- Low-risk patients potentially being managed on an outpatient basis, provided that a care pathway had been defined beforehand 6