Pulmonary embolism treatment approach

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Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-In-Chief: Kashish Goel, M.D.; Rim Halaby, M.D. [2]

This page provides algorithms about the treatment choices. For more details about the medical therapy, click here. For more details about embolectomy, click here.

## Overview[edit | edit source]

Prompt recognition, diagnosis and treatment of pulmonary embolism is critical. Anticoagulant therapy is the mainstay of treatment for patients who are hemodynamically stable. If hemodynamic compromise is present, then fibrinolytic therapy is recommended.

## Step 1: Confirm PE[edit | edit source]

Shown below is an algorithm depicting the initial diagnostic approach to pulmonary embolism.[1][2]

| Does the patient who is suspected to have PE have hypotension or shock?|

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| Yes|

| No

| Suspected high-risk PE|

| Suspected non-high risk PE

| Administer anticoagulation
(in case there are no contraindications)
during the diagnostic workup|

| Is a CT available immediately?|

| What is the pretest probability of PE?
Assess the pretest probability of PE
by using one of the risk score:
\- Wells score
\- Geneva score
\- PERC

| No|

| Yes|

| Order echocardiography|

| Does the patient have RV overload?|

| Low pretest probability|

| Intermediate pretest probability|

| High pretest probability

PE is likely

| Administer anticoagulation
(in case there are no contraindications)
during the diagnostic workup|

| Administer anticoagulation
(in case there are no contraindications)
during the diagnostic workup

No|

| Yes|

| Order CT|

| Order D-dimer|

| Positive|

| Negative|

| Positive|

| Negative|

| Is the patient unstable

no other tests are available?|

| Is the patient stabilized
AND
CT is now available?|

| Order CT|

| PE is excluded|

| Order CT|

| Positive|

| Negative|

| Positive|

| Negative

PE is excluded|

| Consider thrombolytic therapy or embolectomy|

| Order CT|

| PE is confirmed|

| PE is excluded|

| PE is confirmed|

| PE is excluded|

| PE is confirmed|

| PE is excluded

| Positive for PE|

| Negative for PE|

| PE is confirmed|

| PE is excluded|

## Step 2: Initial Treatment[edit | edit source]

Shown below is an algorithm depicting the initial management of pulmonary embolism.[1][2]

| Assess the severity of pulmonary embolism|

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| Massive PE
(also known as high-risk PE)
Cardiogenic shock

Persistent hypotension (≤90mmHg)

Drop of the blood pressure by ≥ 40mmHg for > 15 min[3]

Pulselessness

Profound bradycardia (<40 bpm) with findings of shock[4]|

| Submassive PE
(also know as intermediate-risk PE)
Right ventricular dysfunction
AND/OR
Myocardial injury (Troponin +)|

| Low-risk PE
No cardiogenic shock
AND
No hypotension
AND
No right ventricular dysfunction
AND
No myocardial injury (Troponin -)|

| Provide hemodynamic and respiratory support

Begin high dose unfractionated heparin [3]: Bolus 10.000 U

Continuous infusion of at least 1250 U/hour for a targeted apTT of at least 80 s

Administer rapidly 500-1000 mL of normal saline (Caution with fluid overload)[3]
Have a low threshold for ionotropes (dopamine or dobutamine)[3]

Administer oxygen for hypoxemic patients[3]

| Is there any contraindication for fibrinolytic therapy?|

| Is there any contraindication for anticoagulation therapy?|

| Is there any contraindication for anticoagulation therapy?|

NO|

| YES|

| NO|

| YES|

| NO|

| YES|

Discontinue unfractionated heparin
AND
Begin fibrinolytic therapy|

| Surgical pulmonary embolectomy

Percutaneous catheter embolectomy|

| Anticoagulation therapy
AND
Hospital admission|

| IVC filter
AND
Hospital admission|

| Anticoagulation therapy
AND
Early discharge/home treatment|

| IVC filter
AND
Early discharge/home treatment|

Does the patient fail to improve

Develop cardiogenic shock?

Develop hypotension?|

| Does the patient fail to improve

Develop cardiogenic shock?

Develop hypotension (<90 mmHg)?

Develop respiratory distress (SaO2<95% with Borg score>8 or altered mental status)

Have moderate to severe RV dysfunction (RV hypokinesis or estimated RVSP>40 mmHg)

Elevated biomarkers (troponin> upper limit of normal, BNP>100 pg/mL, or pro-BNP>900 pg/mL)[4]|

YES|

| NO|

| YES|

| NO|

Surgical pulmonary embolectomy

Percutaneous catheter embolectomy|

| Continue with the same treatment|

| Is there any contraindication for fibrinolytic therapy?|

| Continue with the same treatment|

| NO|

| YES|

| Hold anticoagulation and give thrombolytics|

| Surgical pulmonary embolectomy

Percutaneous catheter embolectomy|

| Does the patient fail to improve?|

| YES|

| NO

| Surgical pulmonary embolectomy

Percutaneous catheter embolectomy|

| Continue with the same treatment

### Initial Anticoagulation Therapy[edit | edit source]

Begin initial anticoagulation therapy in:
❑ Confirmed PE

❑ High or intermediate probability of PE while awaiting the diagnostic tests

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Is the patient high risk or non-high risk?

High risk|

| Non-high risk|

❑ Administer IV unfractionated heparin[5]

Does the patient have:
❑ High risk of bleeding

❑ Severe renal failure?

| Yes|

| No

❑ Administer unfractionated heparin:[1]

❑ IV injection

❑ SC injection

❑ Administer ONE of the following:[5]     ❑ SC low molecular weight heparin (1st line)
❑ SC fondaparinux (1st line)
❑ IV unfractionated heparin
❑ SC unfractionated heparin

## Step 3: Long Term Anticoagulation Therapy[edit | edit source]

The long term management of PE depends on whether the episode is the first one or not, whether it is provoked or unprovoked, and on the risk of bleeding of the patient. Among non cancer patients, the first line therapy for long term management of PE is vitamin K antagonists (VKA); whereas the first line treatment among cancer patients is low molecular weight heparin. If long term treatment with VKA is decided, VKA should be started at the same day with heparin allowing for at least 5 days of overlap until the INR is ≥2 for at least 24 hours. Among patients on extended anticoagulation therapy, the risk vs benefits of the anticoagulation therapy should be assessed regularly (for example annually).[2]

| Is this the first episode of PE?|

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| YES|

| NO|

| Is PE provoked?|

| What is the risk of bleeding?|

Yes, transient reversible risk factor|

| Yes, cancer|

| No (unprovoked)|

| Low or moderate|

| High|

Therapy for 3 months

❑ VKA (first line)

❑ LMWH

❑ Dabigatran

❑ Rivaroxaban

| Extended therapy or until cancer is cured

❑ LMWH (first line)

❑ VKA

❑ Dabigatran

❑ Rivaroxaban

| Therapy for ≥ 3 months

❑ VKA (first line)

❑ LMWH

❑ Dabigatran

❑ Rivaroxaban

| Extended therapy

❑ VKA (first line)

❑ LMWH

❑ Dabigatran

❑ Rivaroxaban

| Therapy for 3 months

❑ VKA (first line)

❑ LMWH

❑ Dabigatran

❑ Rivaroxaban

| Re-assess the risk of bleeding|

| Low or moderate|

| High|

| Extended therapy|

| Do not extend the therapy beyond the initial 3 months|

Note that edoxaban[6] has been evaluated for the treatment of VTE and is currently seeking approval for this indication.

## References[edit | edit source]

1. ↑ 1.0 1.1 1.2 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
2. ↑ 2.0 2.1 2.2 Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ; et al. (2012). "Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e419S–94S. doi:10.1378/chest.11-2301. PMC 3278049. PMID 22315268.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link) CS1 maint: PMC format (link)
3. ↑ 3.0 3.1 3.2 3.3 3.4 Kucher N, Goldhaber SZ (2005). "Management of massive pulmonary embolism". Circulation. 112 (2): e28–32. doi:10.1161/CIRCULATIONAHA.105.551374. PMID 16009801.
4. ↑ 4.0 4.1 Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
5. ↑ 5.0 5.1 Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ; et al. (2012). "Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e152S–84S. doi:10.1378/chest.11-2295. PMC 3278055. PMID 22315259.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link) CS1 maint: PMC format (link)
6. ↑ Hokusai-VTE Investigators. Büller HR, Décousus H, Grosso MA, Mercuri M, Middeldorp S; et al. (2013). "Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism". N Engl J Med. 369 (15): 1406–15. doi:10.1056/NEJMoa1306638. PMID 23991658.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)  Review in: Ann Intern Med. 2014 Jan 21;160(2):JC4 Review in: Ann Intern Med. 2014 Mar 18;160(6):JC4

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