From the Guidelines
The treatment plan for acute pulmonary embolism (PE) in the United Kingdom begins with immediate anticoagulation therapy, prioritizing low molecular weight heparin (LMWH) or fondaparinux over unfractionated heparin (UFH) for most patients, as recommended by the 2019 ESC guidelines 1. The choice of anticoagulant should be based on the patient's clinical probability of PE, with LMWH or fondaparinux preferred for patients with high or intermediate clinical probability, while diagnostic workup is in progress 1.
- Key considerations for anticoagulation therapy include:
- Initiating anticoagulation without delay in patients with high or intermediate clinical probability of PE 1
- Using LMWH or fondaparinux as the preferred parenteral anticoagulant for most patients 1
- Starting oral anticoagulation with a direct oral anticoagulant (DOAC) such as apixaban, dabigatran, edoxaban, or rivaroxaban, in preference to a vitamin K antagonist (VKA) 1
- Overlapping parenteral anticoagulation with VKA until an INR of 2.5 (range 2.0-3.0) is reached, for patients treated with VKA 1
- For hemodynamically unstable patients with high-risk PE, consider thrombolysis with alteplase, as recommended by the 2019 ESC guidelines 1.
- Oxygen therapy should be provided to maintain oxygen saturation >94%, and inferior vena cava filter placement should be considered for patients with contraindications to anticoagulation.
- Assessing for underlying causes of PE and addressing them accordingly is crucial to prevent recurrence and reduce mortality. The standard duration of oral anticoagulation is typically at least 3 months, with the risk of bleeding balanced against the risk of further VTE, as recommended by the British Thoracic Society guidelines 1.
From the Research
Treatment Plan for Pulmonary Embolism Acute in United Kingdom
Overview of Treatment Options
- The treatment of pulmonary embolism (PE) typically involves anticoagulation therapy to prevent further clotting and reduce the risk of another PE 2, 3, 4, 5, 6.
- The choice of anticoagulant depends on the patient's clinical presentation, risk factors, and medical history.
Initial Anticoagulation Therapy
- Low-molecular-weight heparins (LMWHs), unfractionated heparin (UFH), and fondaparinux are commonly used for initial anticoagulation therapy in patients with PE 2, 3, 4.
- Direct oral anticoagulants (DOACs) such as rivaroxaban, apixaban, and dabigatran are also effective and may be used as an alternative to traditional anticoagulants in some patients 3, 5.
Long-term Anticoagulation Therapy
- Vitamin K antagonists (VKAs) such as warfarin have been traditionally used for long-term anticoagulation therapy in patients with PE 2, 4.
- DOACs are now widely used for long-term anticoagulation therapy due to their convenience and reduced risk of bleeding compared to VKAs 3, 5.
Thrombolysis
- Thrombolysis is recommended for patients with massive PE (systolic blood pressure < 90 mmHg) and may be considered for patients with submassive PE (intermediate-risk PE) 4, 5.
- Systemic thrombolysis is associated with a reduced risk of mortality in patients with massive PE 5.
Risk Stratification and Follow-up
- Risk stratification using clinical scores, biomarkers, and imaging is essential to determine the best treatment strategy for patients with PE 4, 6.
- Follow-up is mandatory to determine the duration of anticoagulation and to assess for serious long-term complications such as pulmonary hypertension and chronic thromboembolic disease 6.