Pulmonary embolism treatment approach: Difference between revisions

	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
CT
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

VisualWikitext

Latest revision as of 23:53, 29 July 2020

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

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

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

Prompt recognition, diagnosis and treatment of pulmonary embolism is critical. Anticoagulant therapy is the mainstay of treatment for patients who are hemodynamically stable. If hemodynamic compromise is present, then fibrinolytic therapy is recommended.

Step 1: Confirm PE

Shown below is an algorithm depicting the initial diagnostic approach to pulmonary embolism.^[1]^[2]

Does the patient who is suspected to have PE have hypotension or shock?

Yes

No

Suspected high-risk PE

Suspected non-high risk PE

Administer anticoagulation
(in case there are no contraindications)
during the diagnostic workup

Is a CT available immediately?

What is the pretest probability of PE?
Assess the pretest probability of PE
by using one of the risk score:
- Wells score
- Geneva score
- PERC

No

Yes

Order echocardiography

Does the patient have RV overload?

Low pretest probability

Intermediate pretest probability

High pretest probability
OR
PE is likely

Administer anticoagulation
(in case there are no contraindications)
during the diagnostic workup

No

Yes

Order CT

Order D-dimer

Positive

Negative

Positive

Negative

Is the patient unstable
OR
no other tests are available?

Is the patient stabilized
AND
CT is now available?

Order CT

PE is excluded

Order CT

Positive

Negative

Positive

Negative

PE is excluded

Consider thrombolytic therapy or embolectomy

Order CT

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

Step 2: Initial Treatment

Shown below is an algorithm depicting the initial management of pulmonary embolism.^[1]^[2]

Assess the severity of pulmonary embolism

Massive PE
(also known as high-risk PE)
Cardiogenic shock
OR
Persistent hypotension (≤90mmHg)
OR
Drop of the blood pressure by ≥ 40mmHg for > 15 min^[3]
OR
Pulselessness
OR
Profound bradycardia (<40 bpm) with findings of shock^[4]

Submassive PE
(also know as intermediate-risk PE)
Right ventricular dysfunction
AND/OR
Myocardial injury (Troponin +)

Low-risk PE
No cardiogenic shock
AND
No hypotension
AND
No right ventricular dysfunction
AND
No myocardial injury (Troponin -)

Provide hemodynamic and respiratory support

Begin high dose unfractionated heparin ^[3]: Bolus 10.000 U

Continuous infusion of at least 1250 U/hour for a targeted apTT of at least 80 s

Administer rapidly 500-1000 mL of normal saline (Caution with fluid overload)^[3]
Have a low threshold for ionotropes (dopamine or dobutamine)^[3]

Administer oxygen for hypoxemic patients^[3]

Is there any contraindication for fibrinolytic therapy?

Is there any contraindication for anticoagulation therapy?

NO

YES

NO

YES

NO

YES

Discontinue unfractionated heparin
AND
Begin fibrinolytic therapy

Surgical pulmonary embolectomy
OR
Percutaneous catheter embolectomy

Anticoagulation therapy
AND
Hospital admission

IVC filter
AND
Hospital admission

Anticoagulation therapy
AND
Early discharge/home treatment

IVC filter
AND
Early discharge/home treatment

Does the patient fail to improve
OR
Develop cardiogenic shock?
OR
Develop hypotension?

Does the patient fail to improve
OR
Develop cardiogenic shock?
OR
Develop hypotension (<90 mmHg)?
OR
Develop respiratory distress (SaO2<95% with Borg score>8 or altered mental status)
OR
Have moderate to severe RV dysfunction (RV hypokinesis or estimated RVSP>40 mmHg)
OR
Elevated biomarkers (troponin> upper limit of normal, BNP>100 pg/mL, or pro-BNP>900 pg/mL)^[4]

YES

NO

YES

NO

Surgical pulmonary embolectomy
OR
Percutaneous catheter embolectomy

Continue with the same treatment

Is there any contraindication for fibrinolytic therapy?

Continue with the same treatment

NO

YES

Hold anticoagulation and give thrombolytics

Surgical pulmonary embolectomy
OR
Percutaneous catheter embolectomy

Does the patient fail to improve?

YES

NO

Surgical pulmonary embolectomy
OR
Percutaneous catheter embolectomy

Continue with the same treatment

Initial Anticoagulation Therapy

Begin initial anticoagulation therapy in:
❑ Confirmed PE
OR
❑ High or intermediate probability of PE while awaiting the diagnostic tests

Is the patient high risk or non-high risk?

High risk

Non-high risk

❑ Administer IV unfractionated heparin^[5]

Does the patient have:
❑ High risk of bleeding
OR
❑ Severe renal failure?

Yes

No

❑ Administer unfractionated heparin:^[1]

❑ IV injection
OR

❑ SC injection

❑ Administer ONE of the following:^[5]

❑ SC low molecular weight heparin (1st line)

❑ SC fondaparinux (1st line)

❑ IV unfractionated heparin

❑ SC unfractionated heparin

Step 3: Long Term Anticoagulation Therapy

The long term management of PE depends on whether the episode is the first one or not, whether it is provoked or unprovoked, and on the risk of bleeding of the patient. Among non cancer patients, the first line therapy for long term management of PE is vitamin K antagonists (VKA); whereas the first line treatment among cancer patients is low molecular weight heparin. If long term treatment with VKA is decided, VKA should be started at the same day with heparin allowing for at least 5 days of overlap until the INR is ≥2 for at least 24 hours. Among patients on extended anticoagulation therapy, the risk vs benefits of the anticoagulation therapy should be assessed regularly (for example annually).^[2]

Is this the first episode of PE?

YES

NO

Is PE provoked?

What is the risk of bleeding?

Yes, transient reversible risk factor

Yes, cancer

No (unprovoked)

Low or moderate

High

Therapy for 3 months

❑ VKA (first line)
OR
❑ LMWH
OR
❑ Dabigatran
OR
❑ Rivaroxaban

Extended therapy or until cancer is cured

❑ LMWH (first line)
OR
❑ VKA
OR
❑ Dabigatran
OR
❑ Rivaroxaban

Therapy for ≥ 3 months

❑ VKA (first line)
OR
❑ LMWH
OR
❑ Dabigatran
OR
❑ Rivaroxaban

Extended therapy

❑ VKA (first line)
OR
❑ LMWH
OR
❑ Dabigatran
OR
❑ Rivaroxaban

Therapy for 3 months

❑ VKA (first line)
OR
❑ LMWH
OR
❑ Dabigatran
OR
❑ Rivaroxaban

Re-assess the risk of bleeding

Low or moderate

High

Extended therapy

Do not extend the therapy beyond the initial 3 months

Note that edoxaban^[6] has been evaluated for the treatment of VTE and is currently seeking approval for this indication.

References

↑ ^1.0 ^1.1 ^1.2 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; 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.
↑ ^2.0 ^2.1 ^2.2 Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ; 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. PMC 3278049. PMID 22315268.
↑ ^3.0 ^3.1 ^3.2 ^3.3 ^3.4 Kucher N, Goldhaber SZ (2005). "Management of massive pulmonary embolism". Circulation. 112 (2): e28–32. doi:10.1161/CIRCULATIONAHA.105.551374. PMID 16009801.
↑ ^4.0 ^4.1 Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; 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.
↑ ^5.0 ^5.1 Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ; et al. (2012). "Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e152S–84S. doi:10.1378/chest.11-2295. PMC 3278055. PMID 22315259.
↑ Hokusai-VTE Investigators. Büller HR, Décousus H, Grosso MA, Mercuri M, Middeldorp S; et al. (2013). "Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism". N Engl J Med. 369 (15): 1406–15. doi:10.1056/NEJMoa1306638. PMID 23991658. Review in: Ann Intern Med. 2014 Jan 21;160(2):JC4 Review in: Ann Intern Med. 2014 Mar 18;160(6):JC4

Template:WH Template:WS

[pmid18757870-1] 1.0 ^1.1 ^1.2 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; 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.

[pmid22315268-2] 2.0 ^2.1 ^2.2 Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ; 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. PMC 3278049. PMID 22315268.

[pmid16009801-3] 3.0 ^3.1 ^3.2 ^3.3 ^3.4 Kucher N, Goldhaber SZ (2005). "Management of massive pulmonary embolism". Circulation. 112 (2): e28–32. doi:10.1161/CIRCULATIONAHA.105.551374. PMID 16009801.

[pmid21422387-4] 4.0 ^4.1 Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; 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.

[pmid22315259-5] 5.0 ^5.1 Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ; et al. (2012). "Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e152S–84S. doi:10.1378/chest.11-2295. PMC 3278055. PMID 22315259.

[pmid23991658-6] Hokusai-VTE Investigators. Büller HR, Décousus H, Grosso MA, Mercuri M, Middeldorp S; et al. (2013). "Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism". N Engl J Med. 369 (15): 1406–15. doi:10.1056/NEJMoa1306638. PMID 23991658. Review in: Ann Intern Med. 2014 Jan 21;160(2):JC4 Review in: Ann Intern Med. 2014 Mar 18;160(6):JC4

[1]

[2]

[3]

[4]

[5]

[6]

@@ Line 1: / Line 1: @@
+__NOTOC__
+'''To go back to the wikidoc page on [[VTE]], click [[Venous thromboembolism|click here]]'''
+{| class="infobox" style="float:right;"
+|-
+| [[File:Siren.gif|30px|link=Pulmonary embolism resident survival guide]]|| <br> || <br>
+| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
+|}
 {{Pulmonary embolism}}
-'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org]; '''Associate Editor(s)-In-Chief:''' [[Kashish Goel|Kashish Goel, M.D.]]; [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]; {{CZ}}
+'''Editor(s)-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com], {{ATI}}; '''Associate Editor(s)-In-Chief:''' [[Kashish Goel|Kashish Goel, M.D.]]; {{Rim}}
+'''This page provides algorithms about the treatment choices.  For more details about the medical therapy, click [[pulmonary embolism medical therapy|here]].  For more details about embolectomy, click [[pulmonary embolism embolectomy|here]].'''
 ==Overview==
-'''[[Pulmonary embolism]]''' (PE) is a potentially lethal condition, and without treatment has a mortality rate of 30%, thus prompt treatment is of utmost importance. In most cases, [[anticoagulant]] therapy is the mainstay of treatment. A proposed [[Pulmonary embolism treatment algorithm#Treatment algorithm|treatment algorithm]] is presented at the end of this chapter, and all of the contemporary guidelines for the treatment of an acute [[PE]] are listed [[Pulmonary embolism#Guidelines|here]].
+Prompt recognition, diagnosis and treatment of pulmonary embolism is critical. [[Anticoagulant]] therapy is the mainstay of treatment for patients who are [[hemodynamically]] stable.  If [[hemodynamic ]]compromise is present, then [[fibrinolytic]] therapy is recommended.
-==Risk stratification==
+==Step 1: Confirm PE==
-Triage and early risk stratification are two of the most important aspects in the care of a patient with acute [[PE]].
+Shown below is an algorithm depicting the initial diagnostic approach to pulmonary embolism.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
-* [[Pulmonary embolism classification scheme#Low-risk Pulmonary Embolism|Low-risk PE]]: Therapeutic [[anticoagulation]], unless contraindicated.
-* [[Pulmonary embolism classification scheme#Submassive Pulmonary Embolism|Submassive PE]]: If the patient is hemodynamically stable without major [[RV dysfunction]] or infarction, therapeutic anticoagulation should be started. In some cases, [[thrombolysis]] may be indicated.
-* [[Pulmonary embolism classification scheme#Massive Pulmonary Embolism|Massive PE]]: Thrombolysis is indicated and ICU admission may be required. Initial supportive therapies for these patients may include:
-** Respiratory support with oxygen for [[Hypoxemia|hypoxemic]] patients and mechanical [[ventilation]] in cases of severe [[Hypoxemia|hypoxemia]] or pending [[respiratory failure]].
-** Hemodynamic support with intravenous fluids or intravenous vasopressors for [[hypotensive]] patients. Intravenous fluids should be administered with caution as increased right ventricular load can disable the oxygen balance.<ref name="pmid10199533">{{cite journal |author=Mercat A, Diehl JL, Meyer G, Teboul JL, Sors H |title=Hemodynamic effects of fluid loading in acute massive pulmonary embolism |journal=Crit. Care Med. |volume=27 |issue=3 |pages=540–4 |year=1999 |month=March |pmid=10199533|doi=|url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0090-3493&volume=27&issue=3&spage=540|accessdate=2011-12-12}}</ref>
-* If anticoagulation is contraindicated, an [[IVC filter]] is recommended.
+{{familytree/start}}
+{{familytree | | | | | | | | | | | | | | | | A00 | | | | | A00= '''Does the patient who is suspected to have PE have [[hypotension]] or [[shock]]?'''}}
+{{familytree | | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|.| }}
+{{familytree | | | | | | | A01 | | | | | | | | | | | | | | | | | A02 |  A01= Yes| A02= No}}
+{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| }}
+{{familytree | | | | | | | A02 | | | | | | | | | | | | | | | | | A03 |  A02= '''Suspected high-risk PE'''| A03= '''Suspected non-high risk PE'''}}
+{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| }}
+{{familytree | | | | | | | A04 | | | | | | | | | | | | | | | | | |!| A04= ''Administer [[anticoagulation]]'' <br>''(in case there are no contraindications)''<br>''during the diagnostic workup''}}
+{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| }}
+{{familytree | | | | | | | B01 | | | | | | | | | | | | | | | | | B02| B01= '''Is a [[CT]] available immediately?'''| B02= '''What is the pretest probability of PE?''' <br> Assess the pretest probability of PE<br> by using one of the risk score:<br> - [[Wells score]] <br> - [[Geneva score]] <br> - [[PERC]]}}
+{{familytree | | | |,|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | |,|-|v|-|^|-|-|.| | }}
+{{familytree | | | C01 | | | | | | | | | | C02 | | | | | |!| |!| | | | |!| | C01= No| C02= Yes}}
+{{familytree | | | |!| | | | | | | | | | | |!| | | | | | |!| |!| | | | |!| | }}
+{{familytree | | | D01 | | | | | | | | | | |!| | | | | | |!| |!| | | | |!| | D01= '''Order [[echocardiography]]'''}}
+{{familytree | | | |!| | | | | | | | | | | |!| | | | | | |!| |!| | | | |!| | }}
+{{familytree | | | E01 | | | | | | | | | | |!| | | | | E02 | | E03 | | E04 |  E01= '''Does the patient have [[RV]] overload?'''| E02= '''Low pretest probability''' |E03= '''Intermediate pretest probability'''| E04= '''High pretest probability''' <br>OR<br> '''PE is likely'''}}
+{{familytree | | | |!| | | | | | | | | | | |!| | | | | | |!| |!| | | | |!| }}
+{{familytree | | | |!| | | | | | | | | | | |!| | | | | | |!| | N01 | | N02 | N01= ''Administer [[anticoagulation]]'' <br>''(in case there are no contraindications)''<br>''during the diagnostic workup''|N02= ''Administer [[anticoagulation]]'' <br>''(in case there are no contraindications)''<br>''during the diagnostic workup''}}
+{{familytree | |,|-|^|-|-|-|.| | | | | | | |!| | | | | | |!| |!| | | | |!| | }}
+{{familytree | F01 | | | | F02 | | | | | | F03 | | | | | | F04 | | | | |!| F01= No| F02= Yes| F03= '''Order [[CT]]'''| F04= '''Order [[D-dimer]]'''}}
+{{familytree | |!| | | | | |!| | | | | |,|-|^|-|.| | | |,|-|^|-|.| | | |!| }}
+{{familytree | |!| | | | | |!| | | | | G02 | | G03 | | G04 | | G05 | | |!| G01= | G02= Positive| G03= Negative| G04= Positive| G05= Negative}}
+{{familytree | |!| | | |,|-|^|-|.| | | |!| | | |!| | | |!| | | |!| | | |!| }}
+{{familytree | |!| | | H01 | | H02 | | |!| | | |!| | | H03 | | H04 | | H05 | | | H01= Is the patient unstable <br> OR<br> no other tests are available?| H02=Is the patient stabilized <br> AND <br> CT is now available?| H03= '''Order CT'''| H04= PE is excluded| H05= '''Order [[CT]]'''}}
+{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |)|-|-|-|.| | | |)|-|-|-|.| | }}
+{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | L01 | | L02 | | L03 | | L04 | L01= Positive| L02= Negative| L03= Positive| L04= Negative}}
+{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | }}
+{{familytree | I01 | | I02 | | I03 | | I04 | | I05 | | I06 | | I07 | | I08 | | I09 | I01= PE is excluded| I02= Consider [[thrombolytic therapy]] or [[embolectomy]]| I03= Order CT| I04= PE is confirmed| I05=PE is excluded| I06= PE is confirmed| I07= PE is excluded| I08= PE is confirmed| I09= PE is excluded}}
+{{familytree | | | | | | | |,|-|^|-|.| | | | }}
+{{familytree | | | | | | | J01 | | J02 | | | J01= Positive for PE| J02= Negative for PE}}
+{{familytree | | | | | | | |!| | | |!| | | | }}
+{{familytree | | | | | | | K01 | | K02 | | | K01= PE is confirmed| K02= PE is excluded}}
+{{familytree/end}}
-==Initial treatment==
+==Step 2: Initial Treatment==
-===Anticoagulation===
+Shown below is an algorithm depicting the initial management of pulmonary embolism.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
-The most common of mortality in patients with a pulmonary embolism, is a recurrent [[PE]] occurring within a few hours of the initial event<ref name="pmid1560799">{{cite journal |author=Carson JL, Kelley MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, Schwartz JS, Thompson BT, Popovich J, Hobbins TE |title=The clinical course of pulmonary embolism|journal=N. Engl. J. Med. |volume=326 |issue=19 |pages=1240–5 |year=1992 |month=May |pmid=1560799|doi=10.1056/NEJM199205073261902|url=http://dx.doi.org/10.1056/NEJM199205073261902 |accessdate=2011-12-12}}</ref>. Anticoagulation is the cornerstone of therapy in acute [[pulmonary embolism]]<ref name="pmid1560799">{{cite journal |author=Carson JL, Kelley MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, Schwartz JS, Thompson BT, Popovich J, Hobbins TE |title=The clinical course of pulmonary embolism|journal=N. Engl. J. Med. |volume=326 |issue=19 |pages=1240–5 |year=1992 |month=May |pmid=1560799|doi=10.1056/NEJM199205073261902|url=http://dx.doi.org/10.1056/NEJM199205073261902 |accessdate=2011-12-12}}</ref><ref name="pmid10227218">{{cite journal |author=Goldhaber SZ, Visani L, De Rosa M|title=Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER) |journal=Lancet |volume=353|issue=9162|pages=1386–9 |year=1999 |month=April |pmid=10227218 |doi=|url=http://linkinghub.elsevier.com/retrieve/pii/S0140673698075345|accessdate=2011-12-12}}</ref>. After initial risk stratification, immediate treatment should be initiated based on the following guidelines. <ref name="pmid22315268">{{cite journal |author=Kearon C, Akl EA, Comerota AJ, ''et al.'' |title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e419S–94S |year=2012 |month=February |pmid=22315268 |doi=10.1378/chest.11-2301 |url=}}</ref><ref name="pmid21422387">{{cite journal |author=Jaff MR, McMurtry MS, Archer SL, ''et al.'' |title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association |journal=Circulation |volume=123 |issue=16 |pages=1788–830 |year=2011 |month=April |pmid=21422387 |doi=10.1161/CIR.0b013e318214914f |url=}}</ref><ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, ''et al.'' |title=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) |journal=Eur. Heart J. |volume=29 |issue=18 |pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310 |url=}}</ref>:
+{{familytree/start}}
-* Initial treatment with parenteral anticoagulants including subcutaneous [[low molecular weight heparin|Low molecular weight heparin]](such as [[enoxaparin]] and [[dalteparin]]), subcutaneous [[Fondaparinux]] or intravenous [[unfractionated heparin]], unless contraindicated.
-* [[ACCP guidelines]]<ref name="pmid22315268">{{cite journal |author=Kearon C, Akl EA, Comerota AJ, ''et al.'' |title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e419S–94S |year=2012 |month=February |pmid=22315268 |doi=10.1378/chest.11-2301 |url=}}</ref> recommend [[low molecular weight heparin]] or [[fondaparinux]] over intravenous [[unfractionated heparin]].
-* If there is moderate-to-high clinical suspicion of PE, anticoagulation should be initiated while awaiting confirmatory tests.
-* [[Vitamin K antagonists]] such as [[warfarin]] should be started the same day and parenteral anticoagulation should be continued for at least 5 days, and preferably until INR is 2.0 or above for 1-2 days.
-* In patients with suspected or confirmed [[heparin-induced thrombocytopenia]], [[lepirudin]] or [[argatroban]] should be used.
+{{familytree | | | | | | | | | | | A01 | | | | | | | | | | | | A01= '''Assess the severity of pulmonary embolism'''}}
+{{familytree | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|.| | | | | }}
+{{familytree | | | B01 | | | | | | B02 | | | | | | B03 | | | | B01= '''Massive PE''' <br> ''(also known as high-risk PE)'' <br> [[Cardiogenic shock]] <br> OR<br> Persistent [[hypotension]] (≤90mmHg)<br> OR<br> Drop of the [[blood pressure]] by ≥ 40mmHg for > 15 min<ref name="pmid16009801">{{cite journal| author=Kucher N, Goldhaber SZ| title=Management of massive pulmonary embolism. | journal=Circulation | year= 2005 | volume= 112 | issue= 2 | pages= e28-32 | pmid=16009801 | doi=10.1161/CIRCULATIONAHA.105.551374 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16009801  }} </ref><br> OR <br> [[Pulselessness]] <br> OR<br> Profound bradycardia (<40 bpm) with findings of shock<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387  }} </ref>| B02= '''Submassive PE''' <br> ''(also know as intermediate-risk PE)'' <br> Right ventricular dysfunction <br> AND/OR <br> Myocardial injury (Troponin +)| B03= '''Low-risk PE''' <br> No [[cardiogenic shock]] <br> AND <br> No hypotension <br> AND <br> No right ventricular dysfunction <br> AND <br> No myocardial injury (Troponin -)}}
+{{familytree | | | |!| | | | | | | |!| | | | | | | |!| | | | | }}
+{{familytree | | | B04 | | | | | | |!| | | | | | | |!| | | | | B04= '''Provide hemodynamic and respiratory support''' <br>
+Begin high dose unfractionated heparin
+<ref name="pmid16009801">{{cite journal| author=Kucher N, Goldhaber SZ| title=Management of massive pulmonary embolism. | journal=Circulation | year= 2005 | volume= 112 | issue= 2 | pages= e28-32 | pmid=16009801 | doi=10.1161/CIRCULATIONAHA.105.551374 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16009801  }} </ref>: Bolus 10.000 U
+: Continuous infusion of at least 1250 U/hour for a targeted [[apTT]] of at least 80 s
+Administer rapidly 500-1000 mL of normal saline (Caution with fluid overload)<ref name="pmid16009801">{{cite journal| author=Kucher N, Goldhaber SZ| title=Management of massive pulmonary embolism. | journal=Circulation | year= 2005 | volume= 112 | issue= 2 | pages= e28-32 | pmid=16009801 | doi=10.1161/CIRCULATIONAHA.105.551374 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16009801  }} </ref><br>
+Have a low threshold for ionotropes (dopamine or dobutamine)<ref name="pmid16009801">{{cite journal| author=Kucher N, Goldhaber SZ| title=Management of massive pulmonary embolism. | journal=Circulation | year= 2005 | volume= 112 | issue= 2 | pages= e28-32 | pmid=16009801 | doi=10.1161/CIRCULATIONAHA.105.551374 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16009801  }} </ref><br>
+Administer oxygen for hypoxemic patients<ref name="pmid16009801">{{cite journal| author=Kucher N, Goldhaber SZ| title=Management of massive pulmonary embolism. | journal=Circulation | year= 2005 | volume= 112 | issue= 2 | pages= e28-32 | pmid=16009801 | doi=10.1161/CIRCULATIONAHA.105.551374 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16009801  }} </ref><br>}}
+{{familytree | | | |!| | | | | | | |!| | | | | | | |!| | | | | }}
+{{familytree | | | C01 | | | | | | C02 | | | | | | C03 | | | | C01= '''Is there any contraindication for fibrinolytic therapy?'''| C02= '''Is there any contraindication for anticoagulation therapy?'''| C03= '''Is there any contraindication for anticoagulation therapy?'''}}
+{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | | |,|-|^|-|.| | | }}
+{{familytree | D01 | | D02 | | D03 | | D04 | | D05 | | D06 | | D01= NO| D02= YES| D03= NO|D04= YES| D05= NO| D06= YES}}
+{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | }}
+{{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | E01= Discontinue unfractionated heparin <br> AND <br> Begin fibrinolytic therapy| E02= Surgical pulmonary embolectomy <br> OR <br> Percutaneous catheter embolectomy| E03= Anticoagulation therapy <br> AND <br> Hospital admission|E04= IVC filter <br> AND <br>Hospital admission| E05= Anticoagulation therapy<br> AND <br> Early discharge/home treatment| E06= IVC filter <br> AND <br> Early discharge/home treatment}}
+{{familytree | |!| | | | | | | | |!| |!| | | | }}
+{{familytree | F01 | | | | | | | | F02 | | | | F01= '''Does the patient fail to improve''' <br> OR <br> '''Develop [[cardiogenic shock]]?'''<br> OR <br> '''Develop [[hypotension]]?'''| F02= '''Does the patient fail to improve''' <br> OR <br> '''Develop [[cardiogenic shock]]?'''<br> OR <br> '''Develop [[hypotension]] (<90 mmHg)?''' <br> OR <br> '''Develop respiratory distress (SaO2<95% with Borg score>8 or altered mental status)''' <br> OR <br> '''Have moderate to severe RV dysfunction (RV hypokinesis or estimated RVSP>40 mmHg)''' <br> OR <br> '''Elevated biomarkers (troponin> upper limit of normal, BNP>100 pg/mL, or pro-BNP>900 pg/mL)'''<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387  }} </ref>}}
+{{familytree |,|^|-|-|-|.| | | |,|-|^|-|.| | | | }}
+{{familytree | F03 | | F04 | | F05 | | F06 | | | F03= YES| F04= NO| F05= YES| F06= NO}}
+{{familytree | |!| | | |!| | | |!| | | |!| }}
+{{familytree | G01 | | G02 | | G03 | | G04 | | G01= Surgical pulmonary embolectomy <br> OR <br> Percutaneous catheter embolectomy|G02= Continue with the same treatment| G03= '''Is there any contraindication for fibrinolytic therapy?'''| G04= Continue with the same treatment}}
+{{familytree | | | | | | | |,|-|^|-|.| | | }}
+{{familytree | | | | | | | H01 | | H02 | | H01= NO| H02= YES}}
+{{familytree | | | | | | | |!| | | |!| | | | }}
+{{familytree | | | | | | | I01 | | I02 | | I01=Hold anticoagulation and give thrombolytics| I02= Surgical pulmonary embolectomy <br> OR <br> Percutaneous catheter embolectomy}}
+{{familytree | | | | | | | |!| | | }}
+{{familytree | | | | | | | J01 | | J01= '''Does the patient fail to improve?''' }}
+{{familytree | | | | | |,|-|^|-|.| }}
+{{familytree | | | | | K01 | | K02 | K01= YES | K02= NO }}
+{{familytree | | | | | |!| | | |!| | | }}
+{{familytree | | | | | L01 | | L02 | L01= Surgical pulmonary embolectomy <br> OR <br> Percutaneous catheter embolectomy| L02= Continue with the same treatment}}
+{{familytree/end}}
-'''Other salient features of anticoagulant therapy:'''
+===Initial Anticoagulation Therapy===
-*Prevents further clot formation and extension, therefore should be started as early as possible.
+{{Family tree/start}}
-*It has no effect on lysing previously formed clots.
+{{familytree | | | | A01 | | | | | | A01= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Begin initial [[anticoagulation therapy]] in:''' <br> ❑ '''Confirmed PE''' <br>OR <br> ❑ '''High or intermediate probability of PE while awaiting the diagnostic tests''' </div>}}
-*It has no effect in decreasing the size of thrombus.
+{{familytree | | | | |!| | | | | | | }}
-*Warfarin therapy often requires frequent dose adjustment and monitoring of the [[international normalized ratio|INR]]. In PE, the INR goal should be between 2.0 and 3.0.
+{{familytree | | | | B01 | | | | | | B01= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Is the patient high risk or non-high risk?''' </div>}}
-* Certain conditions like [[pericardial tamponade]] and [[aortic dissection]] can mimic [[pulmonary embolism]] and the use of anticoagulants is contraindicated in these medical conditions. Proceed with caution if these conditions are high on the differential.
+{{familytree | |,|-|-|^|-|-|.| | | | }}
+{{familytree | C01 | | | | C02 | | | C01= '''[[Pulmonary embolism classification#Massive Pulmonary Embolism|High risk]]'''| C02= '''[[Pulmonary embolism classification|Non-high risk]]'''}}
+{{familytree | |!| | | | | |!| | | | }}
+{{familytree | D01 | | | | D02 | | | D01=
+<div style="float: left; text-align: left; width: 15em; padding:1em;">❑ Administer IV [[unfractionated heparin]]<ref name="pmid22315259">{{cite journal| author=Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ et al.| title=Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e152S-84S | pmid=22315259 | doi=10.1378/chest.11-2295 | pmc=PMC3278055 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315259  }} </ref>
+</div>| D02= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Does the patient have:''' <br> ❑ '''High risk of [[bleeding]]''' <br> OR <br> ❑ '''Severe [[renal failure]]?''' </div>}}
+{{familytree | | | | | |,|-|^|-|.| | }}
+{{familytree | | | | | E01 | | E02 | E01= '''Yes'''| E02= '''No'''}}
+{{familytree | | | | | |!| | | |!| | }}
+{{familytree | | | | | F01 | | F02 | F01= <div style="float: left; text-align: left; width: 15em; padding:1em;">❑ Administer [[unfractionated heparin]]:<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>
+:❑ IV injection<br> OR<br>
+:❑ SC injection</div>| F02= <div style="float: left; text-align: left; width: 15em; padding:1em;">❑ Administer ONE of the following:<ref name="pmid22315259">{{cite journal| author=Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ et al.| title=Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e152S-84S | pmid=22315259 | doi=10.1378/chest.11-2295 | pmc=PMC3278055 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315259  }} </ref>
+:❑ SC [[low molecular weight heparin]] (1st line)
+:❑ SC [[fondaparinux]] (1st line)
+:❑ IV [[unfractionated heparin]]
+:❑ SC [[unfractionated heparin]]
+</div>}}
+{{familytree/end}}
-===Thrombolysis===
+==Step 3: Long Term Anticoagulation Therapy==
-* [[Pulmonary embolism treatment thrombolysis|Thrombolysis]] is indicated in patients with a [[massive PE]] or those with a [[submassive PE]] who develop or are at risk of developing hypotension (SBP < 90 mmHg), unless contraindicated.
+The long term management of [[PE]] depends on whether the episode is the first one or not, whether it is provoked or unprovoked, and on the risk of bleeding of the patient.  Among non cancer patients, the first line therapy for long term management of [[PE]] is [[vitamin K antagonist]]s (VKA); whereas the first line treatment among cancer patients is [[low molecular weight heparin]].  '''If long term treatment with VKA is decided, VKA should be started at the same day with heparin allowing for at least 5 days of overlap until the [[INR]] is ≥2 for at least 24 hours'''.  Among patients on extended [[anticoagulation therapy]], the risk vs benefits of the [[anticoagulation therapy]] should be assessed regularly (for example annually).<ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
-* Administration of a fibrinolytic via a peripheral intravenous catheter is recommended.
-* FDA recommends a dose of [[alteplase]] 100 mg, as a continuous infusion over 2 hours, supported by [[AHA]]<ref name="pmid21422387">{{cite journal |author=Jaff MR, McMurtry MS, Archer SL, ''et al.'' |title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association |journal=Circulation |volume=123 |issue=16 |pages=1788–830 |year=2011 |month=April |pmid=21422387 |doi=10.1161/CIR.0b013e318214914f |url=}}</ref> and [[ACCP]] guidelines<ref name="pmid22315268">{{cite journal |author=Kearon C, Akl EA, Comerota AJ, ''et al.'' |title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e419S–94S |year=2012 |month=February |pmid=22315268 |doi=10.1378/chest.11-2301 |url=}}</ref>.
-* Withhold anticoagulation during the 2 hours of fibrinolytic infusion.
-* The role of thrombolysis in [[submassive PE]] is not established at this point<ref>Dong B, Jirong Y, Liu G, Wang Q, Wu T. Thrombolytic therapy for pulmonary embolism. ''Cochrane Database Syst Rev'' 2006;(2):CD004437. PMID 16625603.</ref>. Two ongoing trials are investigating this.
-* No large clinical trial has demonstrated mortality benefit of thrombolytic therapy. However, it helps by accelerating clot lysis, improving pulmonary perfusion and right ventricular function<ref name="pmid12374874">{{cite journal |author=Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W |title=Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism |journal=N. Engl. J. Med. |volume=347 |issue=15 |pages=1143–50 |year=2002|month=October|pmid=12374874|doi=10.1056/NEJMoa021274 |url=http://dx.doi.org/10.1056/NEJMoa021274 |accessdate=2011-12-13}}</ref><ref name="pmid2123152">{{cite journal |author=Levine M, Hirsh J, Weitz J, Cruickshank M, Neemeh J, Turpie AG, Gent M |title=A randomized trial of a single bolus dosage regimen of recombinant tissue plasminogen activator in patients with acute pulmonary embolism |journal=Chest |volume=98 |issue=6 |pages=1473–9 |year=1990 |month=December|pmid=2123152|doi=|url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=2123152 |accessdate=2011-12-21}}</ref>
-To read more about dosage, contraindications and guidelines, click [[Pulmonary embolism treatment thrombolysis|'''here''']].
+{{Family tree/start}}
+{{familytree | | | | | | | | | | A01 | | | | | | | | A01= '''Is this the first episode of PE?'''}}
+{{familytree | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | }}
+{{familytree | | | | | B01 | | | | | | | | B02 | | | B01= '''YES'''| B02= '''NO'''}}
+{{familytree | | | | | |!| | | | | | | | | |!| | | | }}
+{{familytree | | | | | C01 | | | | | | | | C02 | | | C01= '''Is PE provoked?'''| C02= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|What is the risk of bleeding?]]'''}}
+{{familytree | |,|-|-|-|+|-|-|-|.| | | |,|-|^|-|.| | }}
+{{familytree | D01 | | D02 | | D03 | | D04 | | D05 | | D01= '''Yes, transient reversible risk factor'''| D02= '''Yes, [[cancer]]'''| D03= '''No (unprovoked)'''| D04= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|Low or moderate]]'''| D05= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|High]]'''}}
+{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | }}
+{{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | E01= '''Therapy for 3 months'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>| E02= '''Extended therapy or until cancer is cured'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[LMWH]] (first line)<br> OR <br> ❑ [[VKA]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>| E03= '''Therapy for ≥ 3 months'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>| E04= '''Extended therapy'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>| E05= '''Therapy for 3 months'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>}}
+{{familytree | | | | | | | | | |!| | | | | | | | | | }}
+{{familytree | | | | | | | | | F01 | | | | | | | | | F01= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|Re-assess the risk of bleeding]]'''}}
+{{familytree | | | | | | | |,|-|^|-|.| | | | | | | | }}
+{{familytree | | | | | | | G01 | | G02 | | | | | | | G01= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|Low or moderate]]'''| G02= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|High]]'''}}
+{{familytree | | | | | | | |!| | | |!| | | | | | | | }}
+{{familytree | | | | | | | H01 | | H02 | | | | | | | H01= '''Extended therapy'''| H02= '''Do not extend the therapy beyond the initial 3 months'''}}
+{{familytree/end}}
-===[[Pulmonary embolism#Surgery:|Surgical procedures]]===
-* [[Pulmonary thrombectomy|Catheter-assisted thrombus removal]] is recommended in patients with [[massive PE]], who have contraindications to thrombolytic therapy or have failed thrombolysis.
-* Thrombectomy is also recommended for patients who are in severe shock that may cause death before thrombolysis takes effect (hours).
-* [[Pulmonary thrombectomy|Pulmonary embolectomy]] is also recommended if a patient with the above conditions fails catheter-assisted embolectomy.
-===[[IVC filter]]===
+''Note that [[edoxaban]]<ref name="pmid23991658">{{cite journal| author=Hokusai-VTE Investigators. Büller HR, Décousus H, Grosso MA, Mercuri M, Middeldorp S et al.| title=Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. | journal=N Engl J Med | year= 2013 | volume= 369 | issue= 15 | pages= 1406-15 | pmid=23991658 | doi=10.1056/NEJMoa1306638 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23991658  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24445714 Review in: Ann Intern Med. 2014 Jan 21;160(2):JC4]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24638182 Review in: Ann Intern Med. 2014 Mar 18;160(6):JC4] </ref> has been evaluated for the treatment of [[VTE]] and is currently seeking approval for this indication.''
-* An [[IVC filter]] is indicated for patients for whom anticoagulation is contraindicated.
-* Anticoagulation should be restarted, once the contraindication is resolved.
-==Long-term treatment==
+==References==
-* After treatment in the hospital, the patient should continue anticoagulation for 3 months for a PE provoked by surgery or nonsurgical transient risk factor.
+{{Reflist|2}}
-* An abnormal [[D-dimer]] level at the end of the treatment course might signal the need for continued treatment with anticoagulation for a first unprovoked pulmonary embolus.<ref name="pmid17065639">{{cite journal |author=Palareti G, Cosmi B, Legnani C, ''et al'' |title=D-dimer testing to determine the duration of anticoagulation therapy |journal=N. Engl. J. Med. |volume=355 |issue=17 |pages=1780-9 |year=2006 |pmid=17065639 |doi=10.1056/NEJMoa054444}}</ref>
+{{WH}}
-* Long-term treatment is usually recommended with vitamin K antagonists like [[warfarin]], unless contraindicated or some special circumstances.
+{{WS}}
-* The recommended therapeutic INR range for patients with PE is 2.0-3.0.
-* Continued warfarin administration needs close monitoring as an outpatient, and the patient should have an appointment with the "anticoagulation clinic" before leaving the hospital.
-===Extended anticoagulation===
-'''Extended treatment''' means extending the anticoagulation therapy beyond the first 3 months. It is recommended in the following scenarios:
-* For a [[pulmonary embolism]] that is unprovoked, the patient's risk should be re-evaluated at 3 months to consider whether extended therapy is warranted.
-* Active cancer.
-* Recurrent [[venous thromboembolism]].
-* Chronic thrombembolic pulmonary hypertension.
-'''Salient features:'''
-* For extended therapy, the continued need for anticoagulation and the risk-benefit ratio should be re-evaluated at periodic intervals (eg, annually).
-* Patients with recurrent [[thromboembolic disease]] with or without anticoagulation, should be evaluated for possible [[Thrombophilia#Laboratory testing|thrombophilias]].
-===Specific circumstances===
-* Malignancy: [[Low molecular weight heparin]] is favored over warfarin based on the results of the CLOT trial.<ref>{{cite journal | author=Lee AY, Levine MN, Baker RI, Bowden C, Kakkar AK, Prins M, Rickles FR, Julian JA, Haley S, Kovacs MJ, Gent M|title=Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. | journal=N Engl J Med| year=2003 | pages=146-53 | volume=349 | issue=2  | id=PMID 12853587}}</ref>
-* Pregnancy: [[Low molecular weight heparin]] is preferred to avoid the known [[teratogenic]] effects of warfarin.
-* Assymptomatic patients who are diagnosed with an incidental PE should be managed with the same criteria as those with symptomatic [[PE]].
-===Newer anticoagulants===
-* [[Dabigatran]] (direct thrombin inhibitor), [[Rivaroxaban]] (Factor Xa inhibitor) and other drugs in same classes provide an alternate option to [[warfarin]]/[[LMWH]] for treatment of [[PE]].
-* '''Advantages''' include availability of an oral formulation, no requirement for frequent monitoring, a predictable effect profile and few (known) drug interactions.
-* '''Disadvantages''' include the currently limited prospective trial data, the theoretical interaction with statins as they are metabolized by the same CYP3A4 enzyme, and the risk of bleeding.
-* Current recommendations still favor [[warfarin]] or [[low molecular weight heparin]] over the new anticoagulants<ref name="pmid22315268">{{cite journal |author=Kearon C, Akl EA, Comerota AJ, ''et al.'' |title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e419S–94S |year=2012 |month=February |pmid=22315268 |doi=10.1378/chest.11-2301 |url=}}</ref> as there is still paucity of data available for the newer agents. It is possible therefore that these recommendations may change.
-==Treatment algorithm==
-{{familytree/start |summary=PE treatment Algorithm.}}
-{{familytree | | | | | | | | GMa | GMa='''Stabilize the patient'''}}
-{{familytree | | | | | | | | |!| }}
-{{familytree | | | | | | | | GPa | GPa='''Is [[anticoagulation]] contraindicated ?'''}}
-{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
-{{familytree | | |JOE| | | | | | | |SIS| | | JOE='''Yes'''|ME=Inconclusive study|SIS='''No'''}}
-{{familytree | | | |!| | | | | | | | | |!| }}
-{{familytree | | |MOM| | | | | | | | SIS | | |MOM=[[Pulmonary embolism#Diagnosis|'''Diagnostic evaluation''']]|SIS=Anticoagulate with SC [[LMWH]] or IV [[Heparin|UFH]]}}
-{{familytree | | | | | | | | | | | | | |!| }}
-{{familytree | | | | | | | | | |A01| |JOE='''PE confirmed'''|A01=[[Pulmonary embolism#Diagnosis|'''Diagnostic evaluation''']]}}
-{{familytree | | | | | |!| | | | | |,|-|^|.| }}
-{{familytree | | | | | |C03| |C04|C01=No further Treatment|C02='''[[Inferior vena cava filter#Pulmonary embolism inferior vena cava filter|Inferior vena cava filter]]'''|C03=PE excluded|C04='''PE confirmed'''}}
-{{familytree | | | | | | | | | | |!| | | |!|}}
-{{familytree | | | | | | | | | |SIS| |B02|SIS=Discontinue Anticoagulants|B02='''Clinicaly severe enough to need [[Thrombolysis]]'''}}
-{{familytree | | | | | | | | | | | | |,|-|^|-|.| }}
-{{familytree | | | | | | | | | | | |JOE| |SIS|JOE='''Yes'''|ME=Inconclusive study|SIS=No}}
-{{familytree | | | | | | | | | | | | |!| | | |!| }}
-{{familytree | | | | | | | | | | | |SIS| |B02|SIS='''Is [[thrombolytic]] Contraindicated?'''|B02=Continue Anticoagulants}}
-{{familytree | | | | | | | | | | |,|-|^|-|.| }}
-{{familytree | | | | | | | | |JOE| |SIS|JOE='''Yes'''|ME=Inconclusive study|SIS='''No'''}}
-{{familytree | | | | | | | | | | |!| | | |!| }}
-{{familytree | | | | | | | | | |SIS| |B02|SIS='''[[Pulmonary thrombectomy|Surgical emblectomy]]''' or '''[[Pulmonary embolism catheter based interventions|catheter based interventions]]'''|B02='''Hold Anticoagulation, Give Thrombolytics then resume Anticoagulations'''}}
-{{familytree | | | | | | | | | | | | | | |!| | | |}}
-{{familytree | | | | | | | | | | | | | |SIS|SIS=Patient shows clinical improvement}}
-{{familytree | | | | | | | | | | | | |,|-|^|-|.| }}
-{{familytree | | | | | | | | | | | |JOE| |SIS|JOE='''No'''|ME=Inconclusive study|SIS='''Yes'''}}
-{{familytree | | | | | | | | | | | | |!| | | |!| }}
-{{familytree | | | | | | | | | | | |SIS| |B02|SIS='''[[Pulmonary thrombectomy|Surgical emblectomy]]''' or '''[[Pulmonary embolism catheter based interventions|catheter based interventions]]'''|B02=Continue anticoagulation}}
-{{familytree/end}}
-==References==
-{{reflist|2}}
 [[Category:Hematology]]
 [[Category:Pulmonology]]
 [[Category:Cardiology]]
 [[Category:Emergency medicine]]
+[[Category:Intensive care medicine]]
-{{WH}}
-{{WS}}

Pulmonary embolism treatment approach: Difference between revisions

Latest revision as of 23:53, 29 July 2020

Overview

Step 1: Confirm PE

Step 2: Initial Treatment

Initial Anticoagulation Therapy

Step 3: Long Term Anticoagulation Therapy

References

Navigation menu