Management of Pulmonary Embolism with Anticoagulation

Immediate Follow-up Assessment

The European Society of Cardiology recommends assessing medication adherence and tolerance to apixaban, including any bleeding complications, in a patient with bilateral pulmonary embolism on apixaban 5mg twice daily 3
Review of renal and hepatic function is necessary as these can affect apixaban metabolism and dosing, according to the European Heart Journal 2

The European Heart Journal suggests identifying whether the pulmonary embolism was provoked by a major transient/reversible risk factor or unprovoked, as this determines treatment duration 3, 5
For pulmonary embolism secondary to a major transient/reversible risk factor, the European Heart Journal recommends discontinuing anticoagulation after 3 months 5, 2
The European Heart Journal advises considering extended anticoagulation of indefinite duration for unprovoked pulmonary embolism or pulmonary embolism associated with persistent risk factors 3, 1
Indefinite oral anticoagulant treatment is recommended for recurrent venous thromboembolism not related to a major transient risk factor, as per the European Heart Journal 5, 2

The European Heart Journal recommends assessing bleeding risk using validated tools to identify and treat modifiable bleeding risk factors 3
High bleeding risk factors include advanced age, previous bleeding, anemia, active cancer, previous stroke, chronic renal/hepatic disease, concomitant antiplatelet therapy, and other serious comorbidities, according to the European Heart Journal 3

Routine re-evaluation at 3-6 months after the acute pulmonary embolism event is recommended by the European Heart Journal 2, 1
For patients receiving extended anticoagulation, regular reassessment of drug tolerance, adherence, renal/hepatic function, and bleeding risk is necessary, as advised by the European Heart Journal 5, 2
Consider referral to a pulmonary hypertension expert center for patients who remain symptomatic with mismatched perfusion defects beyond 3 months, according to the European Heart Journal 2, 1
Implementation of an integrated model of care ensures optimal transition from hospital to ambulatory care, as recommended by the European Heart Journal 1

The European Heart Journal advises against using NOACs like apixaban in patients with severe renal impairment or antiphospholipid antibody syndrome 2
For patients with cancer-associated pulmonary embolism, the European Heart Journal recommends considering indefinite anticoagulation due to the high risk of recurrence 6