What are the latest updates in the management of pulmonary embolism?

Latest Updates in Management of Pulmonary Embolism

Acute Phase Treatment: NOACs Are Now First-Line

Non-vitamin K antagonist oral anticoagulants (NOACs) are recommended as the first choice for anticoagulation treatment in patients eligible for NOACs, with vitamin K antagonists (VKAs) serving as an alternative. 1

Initial Anticoagulation Strategy

• Immediate anticoagulation is mandatory when PE is suspected or confirmed, as this reduces mortality and morbidity 2
• For patients eligible for NOACs (apixaban, rivaroxaban, edoxaban, dabigatran), these agents are preferred over VKAs due to favorable safety profiles 1, 3
• Apixaban dosing: 10 mg twice daily for the first 7 days, then 5 mg twice daily for the remainder of treatment 2
• Rivaroxaban dosing: 15 mg twice daily for 21 days, then 20 mg once daily 4
• NOACs can be started directly or after only 1-2 days of parenteral anticoagulation (LMWH, fondaparinux, or UFH), unlike VKAs which require prolonged bridging 2

High-Risk PE: Escalated Treatment Approach

Rescue thrombolytic therapy is now a Class I recommendation (upgraded from Class IIa) for patients who deteriorate hemodynamically. 1

• Thrombolytic therapy remains first-line treatment for high-risk PE presenting with cardiogenic shock and/or persistent arterial hypotension 1
• Surgical embolectomy or catheter-directed treatment should be considered (upgraded to Class IIa from Class IIb) as alternatives to rescue thrombolytic therapy for patients who deteriorate hemodynamically 1
• Catheter embolectomy or fragmentation may be considered as an alternative to surgical treatment when thrombolysis is absolutely contraindicated or has failed 1

Risk Stratification: Beyond Simple Clinical Scores

A revised risk-adjusted management algorithm now incorporates clinical PE severity, aggravating conditions/comorbidity, and the presence of right ventricular (RV) dysfunction. 1

• RV dysfunction may be present and affect early outcomes even in patients classified as "low risk" based on clinical risk scores—this is a critical caveat 1
• Assessment of PE-related risk is recommended in addition to comorbidity/aggravating conditions and overall death risk 1

Diagnostic Updates

Age-Adjusted D-Dimer

D-dimer testing using an age-adjusted cut-off or adapted to clinical probability should be considered as an alternative to the fixed cut-off level (Class IIa recommendation). 1

• D-dimer should only be measured in patients with low or intermediate clinical probability, or those classified as "PE unlikely" 5
• If D-dimer is negative in low/intermediate probability patients, PE should be rejected without further testing, with 3-month thromboembolic risk below 1% 5

Imaging Advances

• CTPA remains the imaging test of first choice 5
• V/Q SPECT may be considered for PE diagnosis (Class IIb recommendation) 1
• V/Q scintigraphy is valid when CTPA is contraindicated, with normal perfusion scan ruling out PE 5

Duration of Anticoagulation: Abandoning "Provoked vs Unprovoked" Terminology

The 2019 ESC guidelines no longer support terminology such as "provoked" versus "unprovoked" PE/VTE, as it is potentially misleading and not helpful for decision-making regarding anticoagulation duration. 1

New Risk-Based Framework

Discontinue anticoagulation at 3 months for PE provoked by a major transient/reversible risk factor, as annual recurrence risk is <1% 3

Continue anticoagulation indefinitely for:

• Unprovoked PE or proximal DVT (annual recurrence risk exceeds 5%, outweighing bleeding risk) 3
• Recurrent VTE (at least one previous episode) not related to a major transient risk factor 3

Extended Anticoagulation Dosing

A reduced dose of apixaban or rivaroxaban for extended anticoagulation should be considered after the first 6 months of treatment. 1

• For rivaroxaban: 10 mg once daily after initial treatment period 4
• This reduced dosing balances efficacy against bleeding risk for long-term prevention

Cancer-Associated PE: NOAC Option

Edoxaban or rivaroxaban should be considered as an alternative to LMWH for cancer-associated PE, with caution for patients with gastrointestinal cancer due to increased bleeding risk with NOACs. 1

This represents a significant shift from the previous LMWH-only approach for cancer patients.

Pregnancy-Specific Updates

• A dedicated diagnostic algorithm is now proposed for suspected PE in pregnancy 1
• Updated information on radiation absorption related to diagnostic procedures is provided 1
• D-dimer measurement and clinical prediction rules should be considered to rule out PE during pregnancy or post-partum (upgraded to Class IIa) 1

Long-Term Follow-Up: Integrated Care Model

An integrated model of patient care after PE is proposed to ensure optimal transition from hospital to community care, with a comprehensive algorithm for patient follow-up. 1

Mandatory 3-6 Month Re-evaluation

All PE patients should be routinely re-evaluated at 3-6 months after the acute event to assess for chronic complications and determine ongoing anticoagulation needs 3

CTEPH Screening

Further evaluation may be considered for asymptomatic PE survivors at increased risk for CTEPH (upgraded from Class III to Class IIb) 1

• Refer symptomatic patients with mismatched perfusion defects on V/Q scan beyond 3 months to a pulmonary hypertension/CTEPH expert center 3
• Incorporate echocardiography, natriuretic peptides, and/or cardiopulmonary exercise testing results 3
• Do not routinely screen asymptomatic patients for CTEPH, but maintain high clinical suspicion in symptomatic patients 3

Critical Pitfalls to Avoid

• Do not delay anticoagulation when PE is suspected in patients with intermediate to high clinical probability 2
• Do not use NOACs in patients with severe renal impairment (CrCl <30 mL/min for most NOACs, <15 mL/min for rivaroxaban) or antiphospholipid antibody syndrome—use VKA instead 3, 4
• Do not routinely use inferior vena cava filters for extended VTE prevention 3
• Do not fail to use the correct initial higher dose of apixaban (10 mg twice daily for 7 days) or rivaroxaban (15 mg twice daily for 21 days) 2, 4
• Do not stop anticoagulation at 3 months in patients with unprovoked PE without carefully weighing their low bleeding risk, as recurrence rates are substantial (>5% annually) 3