Management of Pulmonary Embolism Without Right Heart Strain

Risk Stratification and Classification

Low-risk PE patients, defined as hemodynamically stable patients without evidence of right ventricular dysfunction or myocardial injury, should be risk-stratified using validated clinical scores, such as PESI class I/II, sPESI score of 0, or meeting Hestia criteria, to identify those suitable for outpatient management, according to the European Respiratory Society and Thorax guidelines 2
The European Society of Cardiology recommends that thrombolytic therapy should NOT be used in low-risk PE, as it is a Class III recommendation 3
Measurement of RV:LV ratio on CT or echocardiographic assessment of RV function is not obligatory for identifying low-risk patients, as stated by the Thorax guidelines 2

The European Respiratory Society recommends that NOACs, such as apixaban, rivaroxaban, edoxaban, or dabigatran, are the preferred first-line anticoagulant for low-risk PE when patients are eligible, due to their ease of use and comparable efficacy/safety 1
The European Heart Journal suggests that LMWH or fondaparinux is recommended for patients who cannot take NOACs, such as those with severe renal dysfunction or pregnancy 5, 6

The Thorax guidelines recommend that low-risk PE patients should be offered outpatient management where robust follow-up pathways exist, and apply the following exclusion criteria before discharge, including hemodynamic instability, oxygen saturation <90% on room air, active bleeding or high bleeding risk, and other medical comorbidities requiring admission 2
The European Respiratory Society guidelines state that if RV dilatation is incidentally found on imaging in otherwise low-risk patients, measure cardiac biomarkers, such as BNP, NT-proBNP, or troponin, to support outpatient management or prompt inpatient admission for observation 2

The European Respiratory Journal recommends that anticoagulation should continue for at least 3 months for all PE patients, and extended anticoagulation beyond 6 months should be considered for patients with unprovoked PE, persistent risk factors, or minor transient/reversible risk factors 1, 7
The European Respiratory Society guidelines suggest that after the first 6 months, reduced-dose apixaban or rivaroxaban should be considered for extended therapy 1

The European Respiratory Journal recommends that routine clinical evaluation is mandatory 3-6 months after acute PE to evaluate for persistent symptoms, ensure appropriate transition from hospital to ambulatory care, and refer symptomatic patients with mismatched perfusion defects on V/Q scan >3 months post-PE to a pulmonary hypertension/CTEPH expert center 1, 2

The European Heart Journal warns that thrombolysis should not be used in hemodynamically stable low-risk PE, as the bleeding risks outweigh any potential benefits, and anticoagulation should not be delayed while awaiting confirmatory testing if clinical probability is high or intermediate 5, 6
The European Heart Journal also recommends monitoring platelet counts in patients receiving heparin to detect heparin-induced thrombocytopenia early, which occurs in 1-3% of patients on unfractionated heparin and ~1% on LMWH 7