Management of Pulmonary Embolism After 3 Months of Treatment

Decision Framework at 3 Months

The American College of Cardiology and European Heart Society recommend discontinuing anticoagulation in patients whose PE was provoked by a major transient/reversible risk factor, as these patients have a low annual recurrence risk (<1%) 1, 2, 3
For hormone-associated PE in women who have stopped estrogen therapy, anticoagulation beyond 3 months is not required, as these patients have approximately 50% lower recurrence risk compared to unprovoked PE 3
The European Society of Cardiology recommends continuing anticoagulation indefinitely in patients with unprovoked PE or proximal DVT, as they have an annual recurrence risk exceeding 5%, which outweighs the bleeding risk of continued anticoagulation 1, 2, 3
Patients with recurrent VTE (at least one previous episode of PE or DVT) not related to a major transient risk factor must receive indefinite anticoagulation, according to the European Heart Journal 2

The European Heart Journal recommends routinely re-evaluating all PE patients at 3-6 months after the acute event to assess for chronic complications and determine ongoing anticoagulation needs 2, 4
Refer symptomatic patients with mismatched perfusion defects on V/Q scan beyond 3 months to a pulmonary hypertension/CTEPH expert center, incorporating echocardiography, natriuretic peptides, and/or cardiopulmonary exercise testing results, as suggested by the European Heart Journal 2

NOACs (apixaban, rivaroxaban, edoxaban, dabigatran) are preferred over VKA for extended treatment in eligible patients due to favorable safety profiles, according to the European Heart Journal 2

Do not routinely screen asymptomatic patients for CTEPH, but maintain high clinical suspicion in symptomatic patients, as recommended by the European Society of Cardiology 2
Do not use inferior vena cava filters routinely for extended VTE prevention, according to the European Heart Journal 2
Do not use NOACs in patients with severe renal impairment (CrCl <25 mL/min) or antiphospholipid antibody syndrome—use VKA instead, as suggested by the European Heart Journal 2
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), according to the Journal of Thrombosis and Haemostasis 1, 3