Abstract
The clinical presentation of pulmonary embolism (PE) varies widely, ranging from only limited symptoms to severe cardiogenic shock. Treatment of PE comprises initial therapy—with low-molecular-weight heparin (LMWH), fondaparinux, or unfractionated heparin—and long-term treatment, most commonly with vitamin-K antagonists (VKAs). Methods of risk stratification, to determine whether a patient will benefit from thrombolysis, are currently under investigation. However, at present, insufficient evidence exists that hemodynamically stable patients who demonstrate echocardiographic right ventricular strain (submassive PE) benefit from thrombolysis. By contrast, thrombolysis is a widely accepted treatment strategy for patients with hemodynamic shock (massive PE). The duration of VKA treatment is commonly 3–12 months and depends on the type of PE and on the balance between the risks of recurrent PE, major bleeding, and the patient's preference. In patients with a malignancy, treatment with LMWH during the first 6 months after diagnosis of PE is recommended. Several new oral anticoagulants, such as factor IIa and factor Xa inhibitors, are now being investigated. For prevention of recurrent PE in situations where anticoagulation is contraindicated, a temporary inferior vena cava filter might be useful. Some patients with PE can be safely treated at home, but few outcome studies in this setting have been published.
Key Points
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Pulmonary embolism (PE) can be effectively treated with anticoagulant medication
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Initial therapy for PE comprises low-molecular-weight heparin, unfractionated heparin, or fondaparinux, and is followed by long-term treatment with oral vitamin-K antagonists
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Duration of long-term anticoagulation is usually 3–12 months and depends on type of PE, risk of recurrence, risk of major bleeding, and the patient's preference
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Tailoring the duration of treatment using biomarkers, such as D-dimer level or presence of residual vein thrombosis, is not yet recommended
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Patients with PE who are hemodynamically unstable (massive PE) should be treated with thrombolysis
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Currently, insufficient evidence exists that hemodynamically stable patients with right ventricular dysfunction (submassive PE) benefit from thrombolysis
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D. Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.
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J. van Es, R. A. Douma, and P. W. Kamphuisen researched data for the article. J. van Es, R. A. Douma, V. E. A. Gerdes, P. W. Kamphuisen, and H. R. Büller contributed to the discussion of content. J. van Es and R. A. Douma wrote the article. J. van Es, R. A. Douma, V. E. A. Gerdes, P. W. Kamphuisen, and H. R. Büller reviewed the manuscript before submission. J. van Es revised the article in response to peer-review and editorial comments.
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van Es, J., Douma, R., Gerdes, V. et al. Acute pulmonary embolism. Part 2: treatment. Nat Rev Cardiol 7, 613–622 (2010). https://doi.org/10.1038/nrcardio.2010.141
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