Pulmonary embolism treatment approach

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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Pulmonary embolism (PE) is a potentially lethal condition, with a mortality rate close to 30 percent without treatment. Thus, prompt therapy is of utmost important. In most cases, anticoagulant therapy is the mainstay of treatment. Acutely, supportive treatments, such as oxygen or analgesia, are often required.

Triage

One of the most important aspects in the care of a patient with acute PE is triage or early risk stratification.

  • Low-risk PE: Therapeutic anticoagulation, unless contraindicated.
  • Submassive PE: If the patient is hemodynamically stable without major RV dysfuncti[[ or infarction, therapeutic anticoagulation should be started. In some cases, thrombolysis may be indicated.
  • Massive PE: Thrombolysis is indicated and ICU admission may be required. Initial supportive therapies in these patients may include:
    • Respiratory support with oxygen for hypoxemic patients or mechanical ventilation in cases of severe hypoxemia or respiratory failure.
    • Hemodynamic support with intravenous fluids or intravenous vasopressors for hypotensive patients. Intravenous fluids should be administered cautiously, as increased right ventricular load can disable the right ventricular oxygen supply-to-demand balance.[1]

Anticoagulation

Initial anticoagulation

Most common reason for mortality is recurrent PE, occurring within the few hours of the initial event[2]. Anticoagulation is the cornerstone of therapy in acute pulmonary embolism[2][3]. After initial risk stratification, immediate treatment should be started based on the following points[4][5][6]:


  • Other salient features:
    • Prevents further clot formation, so should be started as early as possible.
    • It has no effect on pre-existing clot lysis.
    • It has no effect in decreasing the size of thrombus.
    • Warfarin therapy often requires frequent dose adjustment and monitoring of the INR. In PE, INRs between 2.0 and 3.0 are generally considered ideal.
    • Anticoagulation should be used with caution, because certain conditions like pericardial tamponade and aortic dissection can mimic pulmonary embolism, but the use of anticoagulants is contraindicated in these medical conditions.

Long-term anticoagulation

Warfarin therapy is usually continued for 3-6 months, or "lifelong" if there have been previous DVTs or PEs, or none of the usual risk factors is present. An abnormal D-dimer level at the end of treatment might signal the need for continued treatment among patients with a first unprovoked pulmonary embolus.[7]

Extended anticoagulation

'Extended treatment should be considered in patients with:

  1. Active Cancer.
  2. Unprovoked Pulmonary embolism.
  3. Recurrent venous thromboembolism.

Indefinite treatment refers to continued anticoagulation without a pre-scheduled stop date.

If another episode of PE occurs under warfarin treatment

  • The INR window may be increased to e.g. 2.5-3.5 (unless there are contraindications) or
  • Anticoagulation may be changed to a different anticoagulant e.g. low molecular weight heparin.

Anticoaulation may be stopped because of:

  1. Risk of bleeding.
  2. Change in patients preference.

Specific circumstances

In patients with an underlying malignancy, low molecular weight heparin is favored over warfarin based on the results of the CLOT trial.[8]

Similarly, pregnant women are often maintained on low molecular weight heparin to avoid the known teratogenic effects of warfarin.

Newer anticoagulants

These are a class of anticoagulant drugs which act directly upon Factor X in the coagulation cascade, without using antithrombin as a mediator.Advantages of orally administered direct Xa inhibitors lie in the fact that they have a predictable effect, do not require frequent monitoring or re-dosing, are given through the mouth and not by injection and have few (known) drug interactions. Disadvantages include the currently limited prospective experience and the theoretical interactions with statin medication, as they are metabolized at least in part by the same cytochrome enzyme, CYP3A4.

Thrombolysis

Thrombolysis can be used in cases of severe PE, when surgery is not immediately available or possible (e.g. peri-arrest or during cardiac arrest). The only trial that addressed this issue had 8 patients; the four receiving thrombolysis survived, while the four who received only heparin died.[9]

The use of thrombolysis in moderate PE is still debatable. The aim of the therapy is to dissolve the clot, but there is an attendant risk of bleeding or stroke.[10]

No large clinical trial has demonstrated mortality benefit of thrombolytic therapy. However, it helps in the following ways[11]

  1. It accelerates clot-lysis, thereby relieving acute PE.
  2. It improves Right Ventricular function.
  3. It improves pulmonary perfusion and cardiovascular function.[12]

Major risk factor associated with thrombolytic therapy are:

To read more about dosage, contraindications and guidelines, click here.

Treatment algorithm

 
 
 
 
 
 
 
Stabilize the patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is anticoagulation contraindicated ?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic evaluation
 
 
 
 
 
 
 
Anticoagulate with SC LMWH or IV UFH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PE excluded
 
PE confirmed
 
 
 
 
 
Diagnostic evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No further Treatment
 
Inferior vena cava filter
 
 
PE excluded
 
PE confirmed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discontinue Anticoagulants
 
Clinicaly severe enough to need Thrombolysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is thrombolytic Contraindicated?
 
Continue Anticoagulants
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical emblectomy or catheter based interventions
 
Hold Anticoagulation, Give Thrombolytics then resume Anticoagulations
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient shows clinical improvement
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical emblectomy or catheter based interventions
 
Continue anticoagulation


Compression Stockings

Treatment Protocol[13]

 
 
 
 
 
 
 
Stabilize the patient
  • Respiratory Support
  • Hemodynamic Support
  • Anticoagulation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial Treatment options (≤5 Days)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Long term treatment (≥3 Month) (INR target, 2.0-3.0)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Extended treatment (Indefinite) (INR target, 2.0-3.0 OR 1.5-1.9)

References

  1. Mercat A, Diehl JL, Meyer G, Teboul JL, Sors H (1999). "Hemodynamic effects of fluid loading in acute massive pulmonary embolism". Crit. Care Med. 27 (3): 540–4. PMID 10199533. Retrieved 2011-12-12. Unknown parameter |month= ignored (help)
  2. 2.0 2.1 Carson JL, Kelley MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, Schwartz JS, Thompson BT, Popovich J, Hobbins TE (1992). "The clinical course of pulmonary embolism". N. Engl. J. Med. 326 (19): 1240–5. doi:10.1056/NEJM199205073261902. PMID 1560799. Retrieved 2011-12-12. Unknown parameter |month= ignored (help)
  3. Goldhaber SZ, Visani L, De Rosa M (1999). "Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER)". Lancet. 353 (9162): 1386–9. PMID 10227218. Retrieved 2011-12-12. Unknown parameter |month= ignored (help)
  4. 4.0 4.1 Kearon C, Akl EA, Comerota AJ; 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. PMID 22315268. Unknown parameter |month= ignored (help)
  5. Jaff MR, McMurtry MS, Archer SL; 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. Unknown parameter |month= ignored (help)
  6. Torbicki A, Perrier A, Konstantinides S; 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. Unknown parameter |month= ignored (help)
  7. Palareti G, Cosmi B, Legnani C; et al. (2006). "D-dimer testing to determine the duration of anticoagulation therapy". N. Engl. J. Med. 355 (17): 1780–9. doi:10.1056/NEJMoa054444. PMID 17065639.
  8. Lee AY, Levine MN, Baker RI, Bowden C, Kakkar AK, Prins M, Rickles FR, Julian JA, Haley S, Kovacs MJ, Gent M (2003). "Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer". N Engl J Med. 349 (2): 146–53. PMID 12853587.
  9. Jerjes-Sanchez C, Ramirez-Rivera A, de Lourdes Garcia M, Arriaga-Nava R, Valencia S, Rosado-Buzzo A, Pierzo JA, Rosas E. Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism: A Randomized Controlled Trial. J Thromb Thrombolysis 1995;2:227-229. PMID 10608028.
  10. Dong B, Jirong Y, Liu G, Wang Q, Wu T. Thrombolytic therapy for pulmonary embolism. Cochrane Database Syst Rev 2006;(2):CD004437. PMID 16625603.
  11. Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W (2002). "Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism". N. Engl. J. Med. 347 (15): 1143–50. doi:10.1056/NEJMoa021274. PMID 12374874. Retrieved 2011-12-13. Unknown parameter |month= ignored (help)
  12. Levine M, Hirsh J, Weitz J, Cruickshank M, Neemeh J, Turpie AG, Gent M (1990). "A randomized trial of a single bolus dosage regimen of recombinant tissue plasminogen activator in patients with acute pulmonary embolism". Chest. 98 (6): 1473–9. PMID 2123152. Retrieved 2011-12-21. Unknown parameter |month= ignored (help)
  13. Agnelli G, Becattini C (2010). "Acute pulmonary embolism". N Engl J Med. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294.

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