Immediate Treatment for Pulmonary Infarction

Initial Assessment and Management

The European Society of Cardiology recommends immediate anticoagulation therapy with intravenous heparin as soon as pulmonary embolism is suspected, while the diagnostic workup is ongoing, in patients with suspected high-risk pulmonary embolism 1
Bedside transthoracic echocardiography (TTE) should be performed immediately in patients presenting with hemodynamic instability to differentiate suspected high-risk pulmonary embolism from other acute life-threatening conditions 1
Clinical probability of pulmonary embolism should be assessed by looking for sudden collapse with raised jugular venous pressure 2
Isolated dyspnea without cough, sputum, or chest pain is a symptom that should be considered when assessing clinical probability of pulmonary embolism 3
Most patients will present with breathlessness and/or tachypnea (respiratory rate >20/min) 3

The standard intravenous heparin regimen consists of an initial bolus of 5,000-10,000 IU, followed by a maintenance dose of 1,300 IU/hour 4
Alternatively, weight-adjusted dosing can be used, with an initial bolus of 80 IU/kg and a maintenance dose of 18 IU/kg/hour 4, 2
The target APTT should be 1.5-2.5 times control (45-75 seconds) 4, 2

For hemodynamically unstable patients, thrombolytic therapy should be considered immediately, with options including rtPA, streptokinase, and urokinase 2, 4
Heparin should be stopped before thrombolysis and resumed at a maintenance dose after completion 4

The American College of Cardiology recommends administering oxygen to maintain adequate saturation and considering diuretics for patients with pulmonary congestion and volume overload 5
Beta-blockers or calcium channel blockers should be avoided in patients with frank cardiac failure 5
Intra-aortic balloon counterpulsation can be considered for refractory pulmonary congestion 5

In patients with contraindications to anticoagulation, inferior vena cava filter placement should be considered 1

Delaying anticoagulation while waiting for diagnostic confirmation should be avoided, and treatment should be initiated as soon as PE is suspected 1
Discontinuing heparin too early before adequate oral anticoagulation is achieved should be avoided 4
Missing PE diagnosis in elderly patients or those with severe cardiorespiratory disease should be avoided 3

The British Thoracic Society guidelines recommend starting warfarin at 5-10 mg daily for the first 2 days, then adjusting to maintain an INR of 2.0-3.0 for patients with pulmonary embolism 6

Warfarin must be started simultaneously with therapeutic heparin anticoagulation, with a heparin bolus of 80 IU/kg IV, then 18 IU/kg/hour infusion, and a target aPTT of 1.5-2.5 times control for patients with pulmonary embolism 6
Heparin should be continued for at least 5 days and until INR ≥2.0 on two measurements at least 24 hours apart for patients with pulmonary embolism 6

The target INR for all pulmonary embolism patients is 2.0-3.0, according to the British Thoracic Society guidelines 6