What is the management of Pulmonary Embolism (PE) with right ventricular strain?

From the Guidelines

Management of pulmonary embolism (PE) with right heart strain requires prompt intervention with anticoagulation, consideration of thrombolysis, and supportive care. Initial treatment should begin with immediate therapeutic anticoagulation using unfractionated heparin (80 units/kg bolus followed by 18 units/kg/hr infusion) or low molecular weight heparin (enoxaparin 1 mg/kg twice daily) as recommended by the European Society of Cardiology 1. For hemodynamically unstable patients with right heart strain, systemic thrombolysis with alteplase (100 mg IV over 2 hours) should be considered, as it has been shown to reduce death or PE recurrence in high-risk PE patients 1. Some key points to consider in the management of PE with right heart strain include:

• Hemodynamic support is crucial, including judicious fluid management (500-1000 mL crystalloid if hypotensive without overload), vasopressors if needed (norepinephrine 0.05-0.5 mcg/kg/min), and oxygen supplementation to maintain saturation above 90% 1.
• Patients should be monitored in an intensive care setting with continuous cardiac monitoring, frequent vital signs, and serial echocardiograms to assess right ventricular function.
• After stabilization, transition to oral anticoagulants (direct oral anticoagulants or warfarin with INR goal 2-3) for at least 3-6 months is recommended.
• Right heart strain indicates significant clot burden and right ventricular pressure overload, which can lead to right ventricular failure and cardiogenic shock if not promptly addressed, making rapid recognition and aggressive management essential for preventing mortality, as emphasized in recent guidelines 1. The most recent and highest quality study 1 prioritizes the management of PE with right heart strain, focusing on the severity of PE and patient-specific risk factors for bleeding and comorbidities.

From the FDA Drug Label

• Prophylaxis and treatment of venous thrombosis and pulmonary embolism; The management of pulmonary embolism (PE) with right heart strain may involve the use of heparin (IV) for treatment.

• The drug label indicates that heparin is used for the treatment of pulmonary embolism.
• However, it does not provide specific guidance on the management of PE with right heart strain. 2

From the Research

Management of Pulmonary Embolism (PE) with Right Heart Strain

• The management of PE with right heart strain involves anticoagulant therapy to reduce recurrence and mortality 3, 4.
• Low-molecular-weight heparin (LMWH) is at least as effective as unfractionated heparin (UFH) in the treatment of PE, with a similar risk of bleeding 3, 5.
• LMWH offers more predictable pharmacokinetics and anticoagulant effects, making it a preferred choice over UFH in patients with submassive PE 3, 6.

Treatment Options for PE with Right Heart Strain

• Selected patients with massive, life-threatening PE may require intravenously administered thrombolytic drugs, surgical embolectomy, or catheter-based embolectomy 4.
• Inferior vena caval filter should be considered only in patients with an absolute contraindication to, or a documented failure of, anticoagulant therapy 4.
• Direct oral anticoagulant drugs (DOACs) are becoming the agents of first choice for initial treatment of PE due to their simplicity and efficacy 6.

Safety of Anticoagulation during Catheter-Directed Thrombolysis

• Therapeutic anticoagulation with LMWH or UFH infusion during catheter-directed thrombolysis for acute PE appears to be safe, with no significant difference in hemorrhagic complication rates between the two groups 7.
• The use of LMWH or UFH infusion during catheter-directed thrombolysis can improve pulmonary arterial pressure and Miller score, with a low risk of complications 7.