Treatment of Pulmonary and Cardiac Thromboembolism

Risk Stratification

The European Respiratory Society recommends that patients should be stratified based on hemodynamic stability to identify those at high risk of early mortality 2, 3
High-risk PE is characterized by patients with cardiogenic shock and/or persistent arterial hypotension, as defined by the European Heart Journal 4, 2
Intermediate-risk PE includes hemodynamically stable patients with evidence of right ventricular dysfunction, according to the European Respiratory Journal 1, 2
Low-risk PE is defined as hemodynamically stable patients without evidence of right ventricular dysfunction, as stated by the European Heart Journal and European Respiratory Journal 4, 1

The European Heart Journal recommends initiating intravenous unfractionated heparin immediately with a loading dose of 5,000-10,000 units followed by 400-600 units/kg daily as continuous infusion for high-risk PE patients 4, 5
The European Respiratory Journal suggests that low-molecular-weight heparin (LMWH) or fondaparinux is preferred over unfractionated heparin for hemodynamically stable patients 1, 7
The European Respiratory Journal recommends that when oral anticoagulation is initiated, a non-vitamin K antagonist oral anticoagulant (NOAC) such as apixaban, dabigatran, edoxaban, or rivaroxaban is recommended over vitamin K antagonists (VKAs) 1, 7

The European Heart Journal states that absolute contraindications to thrombolysis include hemorrhagic stroke or stroke of unknown origin at any time, ischemic stroke in preceding 6 months, central nervous system damage or neoplasms, recent major trauma/surgery/head injury, gastrointestinal bleeding within the last month, and known active bleeding 8
The European Heart Journal lists relative contraindications to thrombolysis, including transient ischemic attack in preceding 6 months, oral anticoagulant therapy, pregnancy or within 1 week postpartum, non-compressible punctures, traumatic resuscitation, refractory hypertension, advanced liver disease, infective endocarditis, and active peptic ulcer 4, 8

The European Heart Journal recommends surgical pulmonary embolectomy for patients with contraindications to or failure of thrombolysis 4, 9
The European Respiratory Journal suggests that catheter embolectomy or fragmentation of proximal pulmonary arterial clots may be considered as an alternative to surgical treatment when thrombolysis is contraindicated or has failed 4, 1

The European Respiratory Journal recommends that all patients should receive therapeutic anticoagulation for at least 3 months 1, 3
The European Respiratory Journal suggests that extended anticoagulation should be considered for patients with no identifiable risk factor for the index PE event, a persistent risk factor other than antiphospholipid antibody syndrome, or a minor transient/reversible risk factor for the index PE event 1, 6

The European Respiratory Journal recommends routine clinical evaluation 3-6 months after acute PE 1, 2
The European Respiratory Journal suggests implementing an integrated model of care to ensure optimal transition from hospital to ambulatory care 1, 2