Anticoagulation Regimen for Pulmonary Embolism

Initial Anticoagulation

The European Society of Cardiology recommends initiating treatment with low-molecular-weight heparin (LMWH) or fondaparinux subcutaneously, followed by transition to a direct oral anticoagulant (DOAC) such as rivaroxaban or apixaban, which are preferred over vitamin K antagonists for long-term therapy 1, 2, 3
For hemodynamically unstable patients, initiate unfractionated heparin (UFH) intravenously without delay using a weight-adjusted bolus of 80 U/kg followed by continuous infusion at 18 U/kg/h 4, 3
Adjust subsequent UFH doses based on activated partial thromboplastin time (aPTT) to maintain 1.5-2.5 times control value 4, 5
Systemic thrombolytic therapy is recommended for patients presenting with cardiogenic shock or persistent hypotension 5, 3

The European Society of Cardiology recommends DOACs over vitamin K antagonists for all eligible patients 1, 3
Rivaroxaban dosing: 15 mg orally twice daily for 3 weeks, then 20 mg once daily 1, 2
Apixaban is an effective alternative in cancer patients, with a higher dose during the first week, then maintenance dosing 3
Dabigatran requires at least 5-10 days of parenteral anticoagulation before initiation and is non-inferior to warfarin with fewer bleeding episodes in RE-COVER trials 1, 2, 6

The European Society of Cardiology recommends LMWH as the preferred initial and long-term treatment for cancer patients 5, 2
Dalteparin dosing for cancer patients: 200 IU/kg once daily for 1 month, then 150 IU/kg once daily for 5 months 2, 6
UFH is preferred in severe renal dysfunction (CrCl <30 mL/min) 2, 6

Never delay anticoagulation while awaiting diagnostic confirmation in patients with high or intermediate clinical probability 5
Do not stop parenteral anticoagulation before achieving therapeutic INR for 2 consecutive days when using VKAs 4, 1, 2
Avoid aggressive fluid resuscitation in high-risk PE, as it can worsen right ventricular failure 5