Treatment Guidelines for Medium Risk PESI Score Pulmonary Embolism

Initial Anticoagulation Strategy

The European Society of Cardiology recommends starting anticoagulation immediately without waiting for complete diagnostic confirmation, using LMWH or fondaparinux, for most intermediate-risk patients 1, 2
The European Society of Cardiology suggests initiating treatment while diagnostic workup is still in progress if clinical probability is high or intermediate 1, 2
Unfractionated heparin should be reserved for patients at high bleeding risk or those with severe renal dysfunction, as recommended by the European Society of Cardiology 3

The European Society of Cardiology strongly prefers DOACs (apixaban, dabigatran, edoxaban, or rivaroxaban) over vitamin K antagonists for eligible patients 1, 2, 4
Apixaban and rivaroxaban offer the advantage of single-drug regimens without requiring LMWH lead-in, according to the European Society of Cardiology 5, 6
Dabigatran and edoxaban require initial parenteral anticoagulation before transitioning, as recommended by the European Society of Cardiology 5, 6
If VKA is used, overlap with parenteral anticoagulation until INR reaches 2.5 (range 2.0-3.0), as suggested by the European Society of Cardiology 1, 2

Routine primary thrombolysis is not recommended for intermediate-risk PE, according to the European Society of Cardiology 1, 2
Rescue thrombolytic therapy is strongly recommended if the patient develops hemodynamic deterioration despite anticoagulation, as recommended by the European Society of Cardiology 1, 2, 4

Recalculate PESI at 48 hours (PESI-48) to identify candidates for early discharge, as suggested by the European Respiratory Society 6
Patients reclassified as PESI class I/II or sPESI score 0 at 48 hours can be considered for early discharge, according to the European Respiratory Society 6

Close monitoring is essential for intermediate-risk patients, including assessment of RV function by imaging or biomarkers, as recommended by the European Respiratory Society 4
Multidisciplinary team involvement should be considered for selected intermediate-risk cases, according to the European Respiratory Society 4
If hypoxemia develops (SaO2 <90%), administer supplemental oxygen and escalate oxygen delivery as needed, but avoid aggressive fluid challenges, which may worsen RV failure, as recommended by the European Society of Cardiology 1, 7, 8
If hemodynamic compromise develops, vasopressor support with norepinephrine and/or dobutamine should be considered, signaling the need for rescue thrombolysis, according to the European Society of Cardiology 1, 7, 8

Do not use routine thrombolysis in stable intermediate-risk patients, as bleeding risk outweighs benefit, according to the European Society of Cardiology 1, 2
Do not delay anticoagulation while awaiting complete diagnostic confirmation, as recommended by the European Society of Cardiology 1, 2
Do not prescribe DOACs to patients with severe renal impairment, pregnancy, or antiphospholipid syndrome, according to the European Society of Cardiology 1, 5

The American Heart Association acknowledges that no prospective study has demonstrated mortality benefit with any interventional therapy in intermediate-risk PE, and notes the rationale is to "avert possible hemodynamic collapse," but this theoretical benefit does not justify routine use given bleeding risks 9, 10
The European Society of Cardiology does not support routine thrombolysis for intermediate-risk PE to prevent long-term sequelae, and reserves thrombolysis for rescue therapy only if hemodynamic deterioration occurs despite anticoagulation 11

The PEITHO trial (n=1,006) found that tenecteplase reduced death or hemodynamic collapse at 7 days (2.6% vs 5.6%, p=0.015), driven primarily by reduced hemodynamic decompensation (1.6% vs 5.0%), but increased major bleeding (6.3% vs 1.5%, p<0.001) and intracranial hemorrhage (2.0% vs 0.2%) 9, 10
The PEITHO trial also found no mortality benefit at 7 days (2.4% vs 3.2%, p=0.42) and no long-term benefit at 3-year follow-up, with no difference in mortality (20.3% vs 18.0%), persistent symptoms (36.0% vs 30.1%), or CTEPH rates (2.1% vs 3.2%) 9, 10, 11

Assessing for RV dysfunction on echocardiography and elevated cardiac biomarkers (troponin, BNP) is important for risk stratification, but does not justify prophylactic tenecteplase 9
The European Heart Journal recommends against giving tenecteplase prophylactically based on RV dysfunction or biomarker elevation alone 12

Tenecteplase should only be administered if the patient develops persistent hypotension, requirement for vasopressor support, clinical signs of shock, or progressive hemodynamic deterioration despite adequate anticoagulation, according to the European Heart Journal 12

Consider involving a Pulmonary Embolism Response Team (PERT) for borderline hemodynamic instability, progressive clinical deterioration on anticoagulation alone, contraindications to thrombolysis requiring catheter-directed interventions, or severe RV dysfunction with refractory hypoxemia 9, 11