Acute Phase Treatment of Pulmonary Embolism

Pulmonary embolism (PE) is a common and potentially life threatening disease if left untreated. This is due to a natural tendency towards early recurrence of pulmonary emboli which may lead to right ventricular failure. Thus, anticoagulant treatment should be administered to all patients upon high or intermediate clinical probability of acute PE, while awaiting definitive confirmation by imaging procedures. With the exception of severe renal impairment, high bleeding risk, arterial hypotension, and extremes of body weight and age, unfractionated heparin has been replaced by low molecular-weight heparin or fondaparinux given subcutaneously at weight-adjusted doses. In hemodynamically unstable patients with confirmed (high-risk) PE, thrombolysis should be administered without delay; if thrombolysis is absolutely contraindicated or has failed, surgical embolectomy or catheter-based thrombus removal is a valuable alternative. In normotensive (non-high-risk) patients, low-molecular-weight heparin or fondaparinux is adequate treatment in most cases, and thrombolysis is generally not recommended as a first-line therapeutic option. An ongoing randomized trial will determine whether normotensive patients with evidence of right ventricular dysfunction plus myocardial injury may benefit from early thrombolysis. Finally, selected normotensive patients without serious comorbidity or signs of heart failure (low-risk PE) may be candidates for out-of-hospital treatment. This strategy may be facilitated by the use of new oral anticoagulants in the future.