Pulmonary embolism treatment approach

To go back to the wikidoc page on VTE, click click here

| Resident
Survival
Guide

|
|
|

Pulmonary Embolism Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Pulmonary Embolism from other Diseases

Epidemiology and Demographics

Risk Factors

Triggers

Natural History, Complications and Prognosis

Diagnosis

Diagnostic criteria

Assessment of Clinical Probability and Risk Scores

Pulmonary Embolism Assessment of Probability of Subsequent VTE and Risk Scores

History and Symptoms

Physical Examination

Laboratory Findings

Arterial Blood Gas Analysis

D-dimer

Biomarkers

Electrocardiogram

Chest X Ray

Ventilation/Perfusion Scan

Echocardiography

Compression Ultrasonography

MRI

Treatment

Treatment approach

Medical Therapy

IVC Filter

Pulmonary Embolectomy

Pulmonary Thromboendarterectomy

Discharge Care and Long Term Treatment

Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Follow-Up

Support group

Special Scenario

Pregnancy

Cancer

Trials

Landmark Trials

Case Studies

Case #1

Pulmonary embolism treatment approach On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Pulmonary embolism treatment approach

CDC on Pulmonary embolism treatment approach

Pulmonary embolism treatment approach in the news

Blogs on Pulmonary embolism treatment approach

Directions to Hospitals Treating Pulmonary embolism treatment approach

Risk calculators and risk factors for Pulmonary embolism treatment approach

Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-In-Chief: Joseph Nasr, M.D.[2]; Rim Halaby, M.D. [3]

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 acute pulmonary embolism is critical. Management requires early risk stratification, timely anticoagulation unless absolutely contraindicated, and escalation to advanced therapy when there is cardiopulmonary compromise. The 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN guideline introduced five Acute PE Clinical Categories (A to E) to better guide care setting and therapy selection.[1][2] Direct oral anticoagulants are preferred oral agents for most eligible patients. Low molecular weight heparin is preferred over unfractionated heparin for most patients requiring initial parenteral anticoagulation, whereas unfractionated heparin is generally favored when rapid reversal may be needed or advanced therapy is anticipated.[1]

## Step 1: Confirm PE

[edit | edit source]

Shown below is an algorithm depicting the updated initial diagnostic approach to acute pulmonary embolism.[3][1]

Diagnostic notes:

* PERC rule: Apply only when clinical gestalt suggests very low pretest probability.
* Age-adjusted D-dimer: In patients age 50 years or older, threshold = age × 10 μg/L FEU.
* YEARS algorithm: May be used in appropriate patients to reduce unnecessary CTPA.
* Pregnancy: Pregnancy-adapted YEARS may be used in selected pregnant patients.
* CTPA: Preferred imaging modality for most patients when not contraindicated.
* V/Q scan: Alternative when CTPA is contraindicated or undesirable.[1]

| Is the patient suspected to have acute PE hemodynamically unstable?
(SBP <90 mmHg OR drop >40 mmHg lasting >15 min OR vasopressor dependent OR cardiac arrest)|

|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|

| Yes|

| No

| Suspected high-risk PE|

| Suspected non-high-risk PE

| Administer anticoagulation
(if there is no absolute contraindication)
and activate PERT|

| Assess clinical pretest probability of PE
Use a validated tool:
\- Wells score for PE
\- Revised Geneva Score
\- Clinical gestalt

| Is CTPA available immediately?|

| What is the clinical pretest probability?

| No|

| Yes|

| Low clinical probability
or very low risk by gestalt|

| Intermediate clinical probability|

| High clinical probability
or PE most likely

| Order echocardiography|

| Apply PERC rule|

| Order D-dimer
(age adjusted threshold or YEARS algorithm)|

| Administer anticoagulation
(if there is no absolute contraindication)
during the diagnostic workup

| Does the patient have RV overload?|

| Are all 8 PERC criteria met?|

| Is the D-dimer positive?|

| Order CTPA

| Yes|

| No

No|

| Yes|

| PE excluded|

| Order CTPA|

| Positive|

| Negative|

| Positive|

| Negative|

| Is the patient unstable

no other tests are available?|

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

| Order CTPA|

| PE is excluded|

| Order CTPA|

| Positive|

| Negative|

| Positive|

| Negative

PE is excluded|

| Consider advanced therapy
or embolectomy pathway|

| Order CTPA|

| 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|

## Risk Stratification

[edit | edit source]

Risk stratification in acute pulmonary embolism guides level of monitoring, disposition, and consideration of advanced therapies. Contemporary management incorporates hemodynamic status, markers of right ventricular dysfunction, biomarkers, clinical severity scores, and evidence of end-organ hypoperfusion.[1][3]

High-risk features include persistent hypotension, vasopressor requirement, or cardiac arrest.[1]

Clinical severity tools that may support risk assessment include:

* PESI
* sPESI
* Hestia criteria
* Bova score

Markers of increased severity include:

* Right ventricular enlargement or dysfunction on echocardiography or CTPA
* Elevated troponin
* Elevated BNP or NT-proBNP
* Hypoxemia, tachypnea, or escalating oxygen requirement
* Lactate elevation or other evidence of end-organ hypoperfusion[1]

## Step 2: Acute PE Clinical Category and Initial Treatment

[edit | edit source]

Shown below is an algorithm depicting the initial management of acute pulmonary embolism using the 2026 acute PE clinical categories.[1][4]

Definitions used for risk stratification and category assignment:

* Low clinical severity score: PESI ≤85 (Class I to II) OR sPESI = 0 OR Hestia = 0 OR Bova ≤4
* Elevated clinical severity score: PESI >85 OR sPESI ≥1 OR Hestia ≥1 OR Bova >4
* RV dysfunction: RV/LV ratio >1.0 on CTPA or echocardiography, or RV hypokinesis on echo
* Abnormal biomarkers: Troponin above institutional upper limit of normal, or BNP / NT-proBNP elevation
* Respiratory modifier: RR >30/min, OR SpO2 <90% on room air, OR substantial supplemental oxygen requirement, OR need for non-invasive ventilation
* Transient hypotension: SBP <90 mmHg OR drop >40 mmHg lasting <15 min OR responding to IV fluids
* Normotensive shock: End-organ hypoperfusion without persistent hypotension, such as elevated lactate, acute kidney injury, low urine output, mental status change, low cardiac index, or low MAP.[1]

| Assess the clinical severity category of acute PE|

|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|

| Category A or B
Asymptomatic or symptomatic with low clinical severity|

| Category C
Normotensive with elevated clinical severity and no end-organ hypoperfusion|

| Category D or E
Incipient or overt cardiopulmonary failure|

| Begin anticoagulation
Prefer outpatient management only if low risk, reliable follow up, and anticoagulation is accessible|

| Hospitalize
Begin anticoagulation
Monitor for RV dysfunction and deterioration|

| ICU or step-down care
Activate PERT
Begin parenteral anticoagulation
Provide hemodynamic and respiratory support|

| Subsegmental PE?|

| Does the patient deteriorate?|

| Is there an absolute contraindication to systemic thrombolysis?|

YES|

| NO|

| YES|

| NO|

| NO|

| YES|

Individualize anticoagulation decision after assessing DVT, cancer, and recurrence risk|

| Continue standard management|

| Escalate to advanced therapy pathway|

| Continue current treatment and monitoring|

| Hold anticoagulation during thrombolytic infusion and give systemic thrombolysis|

| Catheter-directed therapy

Surgical embolectomy|

| Does the patient fail to improve?|

| YES|

| NO|

| Catheter-directed therapy

Surgical embolectomy

Mechanical circulatory support in selected refractory cases|

| 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 diagnostic tests

|
|
|
|
|
|
|
|

Is the patient high risk or non-high risk?

High risk or advanced therapy likely|

| Non-high risk|

❑ Administer IV unfractionated heparin when rapid reversal may be needed, thrombolysis is planned, or procedures are anticipated.[1]

Does the patient have:
❑ High risk of bleeding

❑ Severe renal failure?

| Yes|

| No

❑ Administer unfractionated heparin:[1]

❑ IV infusion preferred

❑ SC injection in selected patients

❑ Administer ONE of the following:[1]

❑ SC low molecular weight heparin (preferred)
❑ SC fondaparinux
❑ IV unfractionated heparin
❑ SC unfractionated heparin

### Transition to Oral Anticoagulation

[edit | edit source]

Oral Anticoagulation Options for Acute PE Agent  | Parenteral lead-in required  | Initial treatment dose  | Maintenance dose  | Notes

|
|
|
|

Apixaban | No  | 10 mg twice daily for 7 days  | 5 mg twice daily  | Reduced dose 2.5 mg twice daily may be used later for extended therapy in selected patients.[1]
Rivaroxaban | No  | 15 mg twice daily for 21 days  | 20 mg once daily with food  | Reduced dose 10 mg daily may be used later for extended therapy in selected patients.[1]
Edoxaban | Yes  | After at least 5 days of parenteral anticoagulation  | 60 mg once daily  | Dose reduction may be required in selected patients.
Dabigatran | Yes  | After at least 5 days of parenteral anticoagulation  | 150 mg twice daily  | Requires initial parenteral anticoagulation.
Warfarin | Yes  | Start with parenteral overlap  | Dose to target INR 2.0 to 3.0  | Continue overlap for at least 5 days and until INR is at least 2.0 for at least 24 hours.

## Step 3: Long Term Anticoagulation Therapy

[edit | edit source]

The long term management of PE depends on recurrence risk, whether the event was associated with a major reversible risk factor, whether persistent risk factors are present, and the patient’s bleeding risk. For most non-cancer patients, a direct oral anticoagulant is preferred over vitamin K antagonist therapy when not contraindicated. In selected cancer patients, either a DOAC or low molecular weight heparin may be used, with LMWH favored when bleeding risk from certain GI or GU cancers or drug interactions is a concern. The risk versus benefit of extended anticoagulation therapy should be reassessed regularly, such as annually.[1][3][5]

| Has the patient completed the initial treatment phase?|

|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|

| Yes|

| No|

| What is the recurrence risk setting?|

| Continue initial phase therapy|

Major reversible risk factor|

| Active cancer or persistent risk factor|

| No identifiable risk factor|

| Recurrent PE|

| Bleeding risk is high|

Therapy for 3 to 6 months

❑ Apixaban

❑ Rivaroxaban

❑ Edoxaban

❑ Dabigatran

❑ Warfarin

| Extended therapy while cancer is active or persistent risk remains

❑ DOAC

❑ LMWH

| Extended therapy recommended

❑ Full dose DOAC initially
THEN
❑ Reduced dose extended DOAC in selected patients

❑ Warfarin

| Extended therapy recommended

❑ DOAC preferred

❑ Warfarin

| Consider limiting therapy to 3 to 6 months

❑ Reassess bleeding modifiers
❑ Reevaluate periodically

| Reassess the risk of bleeding and recurrence regularly|

| Low or moderate bleeding risk|

| High bleeding risk|

| Continue extended therapy|

| Consider stopping therapy after the initial treatment period|

## Step 4: Post PE Follow Up

[edit | edit source]

Structured follow up after acute pulmonary embolism is important to assess symptoms, anticoagulation adherence, bleeding risk, recovery of functional status, and possible chronic thromboembolic pulmonary disease. Patients with persistent dyspnea or exercise limitation after PE should undergo further evaluation, commonly beginning with a V/Q scan when CTEPD or CTEPH is suspected.[1]

* Confirm access to anticoagulation and follow up plan before discharge.
* Reassess dyspnea, exercise limitation, and functional impairment at follow up visits.
* Evaluate persistent symptoms after approximately 3 months for post-PE syndrome or chronic thromboembolic disease.
* Reassess bleeding risk and the ongoing need for anticoagulation periodically.[1]

## PESI / sPESI Risk Stratification Reference

[edit | edit source]

PESI and sPESI may help identify patients at low risk for short term complications and may support outpatient treatment decisions when used together with clinical judgment and other discharge criteria.[1][3]

* PESI
* sPESI

## Key Practice Points and Common Pitfalls

[edit | edit source]

* Direct oral anticoagulants are preferred oral agents for most eligible patients with acute PE.[1]
* Low molecular weight heparin is preferred over unfractionated heparin for most non-high-risk patients requiring initial parenteral treatment.[1]
* IV unfractionated heparin is preferred when thrombolysis, embolectomy, or another rapid change in therapy may be needed.[1]
* Do not use outpatient treatment casually. It is appropriate only for carefully selected low-risk patients with reliable follow-up and immediate access to anticoagulation.[1]
* Do not treat all intermediate-risk PE the same way. Presence of RV dysfunction, biomarkers, oxygen requirement, and clinical deterioration changes management intensity.[1]
* Systemic thrombolysis is not routine therapy for stable patients. It is mainly reserved for patients with hemodynamic collapse or selected patients with significant deterioration and acceptable bleeding risk.[1]
* Do not overuse IVC filters. They are generally reserved for acute VTE with an absolute contraindication to anticoagulation or selected failure cases.
* Do not forget follow up. Persistent dyspnea or functional limitation after PE should prompt evaluation for post-PE syndrome or chronic thromboembolic disease.[1]
* Reassess anticoagulation duration deliberately. Extended therapy depends on recurrence risk, bleeding risk, and whether the event was associated with a major reversible risk factor.[1][3]

## References

[edit | edit source]

1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 Creager MA, Barnes GD, Giri J; et al. (2026). "2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults". J Am Coll Cardiol. doi:10.1016/j.jacc.2025.11.005.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
2. ↑ Creager MA, Barnes GD, Giri J; et al. (2026). "2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults". Circulation. doi:10.1161/CIR.0000000000001415.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
3. ↑ 3.0 3.1 3.2 3.3 3.4 Konstantinides SV, Meyer G, Becattini C; et al. (2020). "2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism". Eur Heart J. doi:10.1093/eurheartj/ehz405.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
4. ↑ Dudzinski DM; et al. (2026). "2026 Acute Pulmonary Embolism Guideline-at-a-Glance". J Am Coll Cardiol. doi:10.1016/j.jacc.2025.12.023.CS1 maint: Explicit use of et al. (link)
5. ↑ Falanga A; et al. (2023). "Venous thromboembolism in cancer patients: ESMO Clinical Practice Guideline". Ann Oncol. doi:10.1016/j.annonc.2022.12.014.CS1 maint: Explicit use of et al. (link)

Template:WH Template:WS