PULMONARY EMBOLISM-MANAGEMENT

SUMMARY

1. Asymptomatic or Subsegmental PE: risk of 90 day mortality greater for treatment (3%) than no treatment (2%). Consider not treating especially if a bleeding risk is present.

2. Massive PE: consider thrombolysis early.

3. Novel Oral Anticoagulants (NOAC’s)/Direct Oral Anticoagulants (DOAC's): preferred for convenience of use. Rivoraxaban, Apixaban (lower bleeding risk)
. Cannot be used in renal failure (CrCl < 30mls/min).

4. Warfarin: requires INR monitoring regularly and be aware of medication interactions. Should be commenced with heparin, which is continued for 48 hrs till theraputic INR achieved. Teratogenic, increases fetal bleeding.

5. LMWH (fractionated heparin): preferred over UHF for PE. Indicated in the presence of malignancy, preferred in pregnancy. Achieves theraputic dosing immediately, not titratable & has a longer half-life. Risk of HIT.
6. Fondaparinux: use in patients with history of HIT, unless Cr clearance < 30mL/min.

7. Argatroban: direct thrombin inhibitor, use in those with renal impairment.

8. UFH (unfractionated heparin): initial therapy in massive PE (prior to thrombectomy/embolectomy). Also used in patients with a planned procedures (need for rapid reversal), poor renal function & extremes of height & weight.

9. Adjunctive treatment: O₂ for hypoxia, IVF for hypovolemia & to raise preload in dilated, strained RV. In shock, norepinephrine is the vasopressor of choice. Mechanical ventilation for respiratory failure.

10. Vena cava filters: for recurring VTE with adequate anticoagulation or if anticoagulants are contraindicated.

Reference(s)

Wilkinson, I. (2017). Oxford handbook of clinical medicine. Oxford: Oxford University Press.
Hannaman, R. A., Bullock, L., Hatchell, C. A., & Yoffe, M. (2016). Internal medicine review core curriculum, 2017-2018. CO Springs, CO: MedStudy.
Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited. https://www.tg.org.au [Accessed 2021].