Management of Pulmonary Embolism

Risk Stratification and Treatment

The American College of Cardiology recommends immediate anticoagulation in all patients with suspected pulmonary embolism (PE) while diagnostic workup proceeds, with treatment stratified by hemodynamic stability: high-risk PE requires systemic thrombolysis, intermediate-risk PE is managed with anticoagulation alone, and low-risk PE is treated with anticoagulation preferably using NOACs over warfarin 1
High-risk PE is characterized by the presence of shock or persistent hypotension, and requires immediate intervention with systemic thrombolysis and anticoagulation 1
Intermediate-risk PE is hemodynamically stable but with evidence of right ventricular dysfunction, and is managed with anticoagulation alone, with rescue thrombolytic therapy if hemodynamic deterioration occurs 1
Low-risk PE is hemodynamically stable without right ventricular dysfunction, and is treated with anticoagulation, preferably using NOACs over warfarin 1

The European Society of Cardiology recommends systemic thrombolysis as the first-line treatment for high-risk PE, unless absolutely contraindicated, with alteplase 100 mg IV over 90 minutes (accelerated MI regimen) 1, 2, 3
Unfractionated heparin should be initiated after 3 hours of thrombolysis, preferably weight-adjusted 2
Surgical pulmonary embolectomy is recommended via median sternotomy with normothermic cardiopulmonary bypass when thrombolysis is contraindicated or has failed 3

The American College of Chest Physicians recommends anticoagulation with low-molecular-weight heparin (LMWH) or fondaparinux over unfractionated heparin for most patients with PE 1, 4
NOACs are recommended over vitamin K antagonists for most patients, with rivaroxaban 15 mg PO twice daily with food for 21 days, then 20 mg once daily with food, or apixaban 10 mg PO twice daily for 7 days, then 5 mg twice daily 1, 5
Warfarin is an alternative, with a target INR 2.5 (range 2.0-3.0) if NOACs are contraindicated 5, 4

In pregnancy, fixed-dose LMWH based on early pregnancy weight is the treatment of choice, with careful monitoring of anticoagulation and avoidance of spinal/epidural procedures within 24 hours of last LMWH dose 5
IVC filters are not recommended for routine use, but may be considered in patients with absolute contraindications to anticoagulation or PE recurrence despite therapeutic anticoagulation 1, 4
Post-PE follow-up at 3-6 months is essential, with implementation of an integrated care model to ensure optimal transition from hospital to ambulatory care, and referral of symptomatic patients with mismatched perfusion defects on V/Q scan beyond 3 months to a pulmonary hypertension/CTEPH expert center 5, 1