Pulmonary embolism medical therapy
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Pulmonary Embolism Microchapters |
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Diagnosis |
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Pulmonary Embolism Assessment of Probability of Subsequent VTE and Risk Scores |
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Treatment |
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Follow-Up |
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Special Scenario |
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Trials |
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Case Studies |
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Pulmonary embolism medical therapy On the Web |
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Directions to Hospitals Treating Pulmonary embolism medical therapy |
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Risk calculators and risk factors for Pulmonary embolism medical therapy |
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
In most cases, anticoagulant therapy is the mainstay of treatment.
Treatment Protocol[1]
Stabilize the patient
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Initial Treatment options (≤5 Days)
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| 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) | |||||||||||||||||||
Anticoagulation
- Subcutaneous or Intravenous Low molecular weight heparin.
- Hemodynamically stable patients.
- Thrombolysis
- High Risk Hemodynamically stable patients.
- Hemodynamically Unstable patients.
- Percutaneous mechanical thrombectomy.
- High risk patients with absolute contraindications to Thrombolytics.
- Patients with failed Thrombolysis.
- Low molecular weight heparin is preferred over Vitamin K antagonist.
Dosage
Another validated nomogram has proposed the following dosage[2].
- Low molecular weight heparin
- Enoxaparin : 1 mg/Kg body weight (twice daily).
- Tinzaparin : 175 U/Kg body weight (once daily).
- Factor Xa Inhibitors
- Fondaparinux :
- Patient weighing less than 50 Kg (110 lb) : 5 mg (once daily).
- Patient weighing 50 Kg (110 lb) to 110 Kg (220 lb): 7.5 mg (once daily).
- Patient weighing more than 100 Kg (220 lb) : 10 mg (once daily).
- Fondaparinux :
- Unfractionated heparin
- Loading Dose: 80 IU/Kg or 5000 IU
- Mantainace Dose: 18 IU/Kg/Hr to achieve a target aPTT 1.5 to 2.5 times the normal value.
ESC Guidelines treatment High-risk pulmonary embolism (DO NOT EDIT)
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Class I1. Anticoagulation with unfractionated heparin should be initiated without delay in patients with high-risk PE. (Level of Evidence: A) 2. Systemic hypotension should be corrected to prevent progression of RV failure and death due to PE. (Level of Evidence: C) 3. Vasopressive drugs are recommended for hypotensive patients with PE. (Level of Evidence: C) Class IIa4. Dobutamine and dopamine may be used in patients with PE, low cardiac output and normal blood pressure. (Level of Evidence: B) Class III5. Aggressive fluid challenge is not recommended. (Level of Evidence: B) Class I6. Oxygen should be administered in patients with hypoxaemia.(Level of Evidence: C) 7. Thrombolytic therapy should be used in patients with high-risk PE presenting with cardiogenic shock and/or persistent arterial hypotension.(Level of Evidence: A) 8. Surgical pulmonary embolectomy is a recommended therapeutic alternative in patients with high-risk PE in whom thrombolysis is absolutely contraindicated or has failed.(Level of Evidence: C) Class IIb9.Catheter embolectomy or fragmentation of proximal pulmonary arterial clots may be considered as an alternative to surgical treatment in high-risk patients when thrombolysis is absolutely contraindicated or has failed. (Level of Evidence: C) |
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ESC Guidelines treatment Non-high-risk pulmonary embolism (DO NOT EDIT)
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Class I1. Anticoagulation should be initiated without delay in patients with high or intermediate clinical probability of PE while diagnostic workup is still ongoing. (Level of Evidence: C) 2. Use of LMWH or fondaparinux is the recommended form of initial treatment for most patients with non-high-risk PE. (Level of Evidence: A) 3. In patients at high risk of bleeding and in those with severe renal dysfunction, unfractionated heparin with an aPTT target range of 1.5–2.5 times normal is a recommended form of initial treatment. (Level of Evidence: C) 4. Initial treatment with unfractionated heparin, LMWH or fondaparinux should be continued for at least 5 days and (Level of Evidence: A) may be replaced by vitamin K antagonists only after achieving target INR levels for at least 2 consecutive days (Level of Evidence: C) Class IIb5. Routine use of thrombolysis in non–high-risk PE patients is not recommended, but it may be considered in selected patients with intermediate-risk PE (Level of Evidence: B) Class III6. Thrombolytic therapy should be not used in patients with low-risk PE (Level of Evidence: B) |
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ESC Guidelines Recommendations Long-term treatment (DO NOT EDIT)
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Class I1. For patients with PE secondary to a transient (reversible) risk factor, treatment with a VKA is recommended for 3 months.(Level of Evidence: A) 2. For patients with unprovoked PE, treatment with a VKA is recommended for at least 3 months. (Level of Evidence: A) 3. For patients with a second episode of unprovoked PE, long-term treatment is recommended. (Level of Evidence: A) 4. In patients who receive long-term anticoagulant treatment, the risk/benefit ratio of continuing such treatment should be reassessed at regular intervals. (Level of Evidence: C) 5. In patients with PE, the dose of VKA should be adjusted to maintain a target INR of 2.5 (range 2.0–3.0) regardless of treatment duration. (Level of Evidence: A) Class IIb6. Patients with a first episode of unprovoked PE and low risk of bleeding, and in whom stable anticoagulation can be achieved, may be considered for long-term oral anticoagulation. (Level of Evidence: B) Class IIa7. For patients with PE and cancer, LMWH should be considered for the first 3–6 months (Level of Evidence: B) after this period, anticoagulant therapy with VKA or LMWH should be continued indefinitely or until the cancer is considered cured. (Class I,Level of Evidence: C) |
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Guidelines Resources
- Guidelines on the diagnosis and management of acute pulmonary embolism[3].
References
- ↑ Agnelli G, Becattini C (2010). "Acute pulmonary embolism". N Engl J Med. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294.
- ↑ Raschke RA, Gollihare B, Peirce JC (1996). "The effectiveness of implementing the weight-based heparin nomogram as a practice guideline". Arch Intern Med. 156 (15): 1645–9. PMID 8694662.
- ↑ 3.0 3.1 3.2 3.3 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP (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. Retrieved 2011-12-07. Unknown parameter
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