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Feature Article

Acute pulmonary embolism: an update on management

BETTY CHEN, EMILY STONE

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© KO STUDIOS
© KO STUDIOS

Abstract

Acute pulmonary embolism can be managed with thrombolysis, anticoagulation and newer interventional therapies. There is increasing evidence to guide the duration of anticoagulation and type of agent used, including warfarin, nonvitamin K antagonist oral anticoagulants and low molecular weight heparins.

Key Points

  • Treatment options for managing pulmonary embolism (PE) include anticoagulation and, in haemodynamically unstable PE, thrombolysis. It is less clear whether thrombolysis is of benefit in patients with submassive PE; in patients with lower-risk PE, anticoagulation alone is recommended.
  • Duration of anticoagulation for PE is guided by risk of recurrence, risk of bleeding and, if appropriate, patient preference.
  • Anticoagulation should continue for at least three months if PE was provoked by a transient risk factor; consider six months of anticoagulation if there is no obvious precipitant.
  • Nonvitamin K antagonist oral anticoagulants (NOACs) are noninferior to vitamin K antagonists in most patients with PE, but there is no evidence regarding their use in massive PE or pregnancy.
  • Aspirin is better than placebo for prevention of venous thromboembolism (VTE) recurrence, but standard-dose warfarin and NOACs are twice as effective as aspirin.
  • Management of VTE during pregnancy should be with low molecular weight heparin (LMWH) for the remainder of pregnancy and until at least six weeks postpartum or three months in total.
  • Patients with cancer benefit from LMWH over vitamin K antagonists in treatment of PE, possibly independent of PE risk.
  • Inferior vena cava filters confer no additional benefit in patients who can tolerate anticoagulation for PE.
  • Testing for heritable thrombophilias should not be routine after VTE.

Figures

© KO STUDIOS
© KO STUDIOS