What is the appropriate management and treatment plan for a patient admitted with pulmonary embolism?

Assessment and Plan: Pulmonary Embolism

Risk Stratification

Immediately classify this patient's PE based on hemodynamic stability to determine treatment intensity. 1, 2

• High-risk PE: Presence of shock (systolic BP <90 mmHg for >15 minutes) or sustained hypotension requiring vasopressors 1, 2
• Intermediate-risk PE: Hemodynamically stable but with evidence of right ventricular dysfunction on imaging or elevated cardiac biomarkers (troponin, BNP) 1, 2
• Low-risk PE: Hemodynamically stable without RV dysfunction or biomarker elevation 1, 2

Immediate Anticoagulation

Initiate anticoagulation immediately upon admission, even before imaging confirmation if clinical probability is high or intermediate. 1

For High-Risk PE (Hemodynamically Unstable):

• Start unfractionated heparin (UFH) with weight-adjusted bolus of 80 units/kg IV (or 5,000-10,000 units) followed by continuous infusion at 18 units/kg/hour 1, 3
• Target aPTT 1.5-2.5 times control (check aPTT every 4 hours initially until therapeutic, then daily) 3
• Alternative monitoring: Anti-Xa level 0.3-0.7 units/mL 4

For Intermediate or Low-Risk PE (Hemodynamically Stable):

• Prefer low molecular weight heparin (LMWH) or fondaparinux over UFH 1, 2
• Enoxaparin 1 mg/kg subcutaneously every 12 hours 5
• Transition to oral anticoagulation with a NOAC (apixaban, rivaroxaban, edoxaban, or dabigatran) is preferred over warfarin 1

Thrombolytic Therapy Decision

High-Risk PE:

• Administer systemic thrombolytic therapy (alteplase 50 mg IV bolus) unless contraindicated 1
• If thrombolysis contraindicated or failed: Consider surgical pulmonary embolectomy or percutaneous catheter-directed treatment 1

Intermediate or Low-Risk PE:

• Do NOT routinely use thrombolysis 1
• Reserve rescue thrombolysis only for hemodynamic deterioration despite anticoagulation 1

Hemodynamic Support (High-Risk PE Only)

• Provide supplemental oxygen to maintain SpO2 >90% 1, 2
• Administer norepinephrine and/or dobutamine for hypotension 1, 2
• Consider ECMO in combination with surgical embolectomy or catheter-directed treatment for refractory circulatory collapse 1

IVC Filter Consideration

IVC filters should be considered ONLY in these specific scenarios: 1, 6

• Absolute contraindication to anticoagulation (active bleeding) 1, 6
• Recurrent PE despite therapeutic anticoagulation 1, 6
• Routine use of IVC filters is NOT recommended 1

Monitoring Plan

• Check baseline: aPTT, PT/INR, CBC with platelet count, creatinine, troponin, BNP 1
• Monitor aPTT every 4 hours until therapeutic range achieved (1.5-2.5 times control), then daily 3
• Monitor platelet count every 2-3 days to detect heparin-induced thrombocytopenia (HIT) 3
• Monitor hematocrit and assess for occult bleeding throughout hospitalization 3

Duration of Anticoagulation

• Minimum 3 months of therapeutic anticoagulation for all PE patients 1, 6
• For unprovoked PE: Consider indefinite anticoagulation due to 50% recurrence risk within 10 years 6
• For provoked PE (major transient risk factor): Discontinue after 3 months 1
• For recurrent VTE: Continue indefinitely 1, 6

Special Contraindications

NOACs are contraindicated in: 1

• Severe renal impairment (CrCl <30 mL/min) 1
• Pregnancy and lactation 1
• Antiphospholipid antibody syndrome (use warfarin with target INR 2.0-3.0) 1, 6

Disposition Planning

• High-risk PE: ICU admission for continuous monitoring 1, 2
• Intermediate-risk PE: Telemetry bed with close monitoring 1
• Low-risk PE: Consider early discharge (within 24-48 hours) with outpatient anticoagulation management if patient is stable, has adequate home support, and reliable follow-up 1

Follow-Up

• Schedule outpatient follow-up at 3-6 months to reassess anticoagulation duration, screen for chronic thromboembolic pulmonary hypertension (CTEPH) if persistent dyspnea, and monitor for bleeding complications 6