Anticoagulation Management for Pulmonary Embolism

Initial Treatment and Duration

The European Society of Cardiology recommends continuing the current anticoagulation regimen for a minimum total duration of 3 months from the initial diagnosis for patients with pulmonary embolism who are already on therapeutic anticoagulation 1, 2.
For patients with pulmonary embolism secondary to a major transient/reversible risk factor, the European Society of Cardiology recommends discontinuing anticoagulation after 3 months total 1, 4.
For patients with first unprovoked pulmonary embolism, the European Society of Cardiology recommends continuing anticoagulation for a minimum of 3 months total, then reassessing for extended therapy 1, 2, 3.

The European Society of Cardiology recommends initiating low molecular weight heparin (LMWH) immediately for hemodynamically stable patients with pulmonary embolism who have not been anticoagulated 1.
For hemodynamically unstable patients or those with high-risk pulmonary embolism, the European Society of Cardiology recommends using unfractionated heparin with IV bolus of 80 U/kg followed by continuous infusion at 18 U/kg/hour, targeting aPTT of 1.5-2.5 times normal 1, 5.

The European Society of Cardiology recommends assessing for signs of bleeding complications, which are most common in the first weeks of therapy, and monitoring platelet counts every 2-3 days if still on heparin products to detect heparin-induced thrombocytopenia 1, 6.
The European Society of Cardiology recommends evaluating treatment adherence and tolerance, and assessing bleeding risk factors including age, renal function, and concurrent medications 1, 3.

The European Society of Cardiology recommends not discontinuing anticoagulation prematurely, as the minimum duration is 3 months from initial diagnosis 1, 2, 3.
The European Society of Cardiology recommends not switching anticoagulant regimens without clear indication, and not using NOACs in patients with severe renal impairment (CrCl <30 mL/min), during pregnancy, or in antiphospholipid antibody syndrome 1, 4.