Management of Venous Thromboembolisms: Part II. The Consensus for Pulmonary Embolism and Updates

Abstract

Pulmonary embolism (PE) is a potential life-threatening condition and risk-adapted diagnostic and therapeutic management conveys a favorable outcome. For patients at high risk for early complications and mortality, prompt exclusion or confirmation of PE by imaging is the key step to initiate and facilitate reperfusion treatment. Among patients with hemodynamic instability, systemic thrombolysis improves survival, whereas surgical embolectomy or percutaneous intervention are alternatives in experienced hands in scenarios where systemic thrombolysis is not the best preferred thromboreduction measure. For patients with suspected PE who are not at high risk for early complications and mortality, the organized approach using a structured evaluation system to assess the pretest probability, the age-adjusted D-dimer cut-offs, the appropriate selection of imaging tools, and proper interpretation of imaging results is important when deciding the allocation of treatment strategies. Patients with PE requires anticoagulation treatment. In patients with cancer and thrombosis, low-molecular-weight heparin (LMWH) used to be the standard regimen. Recently, three factor Xa inhibitors collectively show that non-vitamin K oral anticoagulants (NOACs) are as effective as LMWH in four randomized clinical trials. Therefore, NOACs are suitable and preferred in most conditions. Finally, chronic thromboembolic pulmonary hypertension is the most disabling long-term complication of PE. Because of its low incidence, the extra caution should be given when managing patients with PE.

Keywords: Anticoagulants; Diagnosis; Pulmonary embolism; Treatment.

Figure 1

Diagnosis flowchart for patients with stable hemodynamic and suspected pulmonary embolism. * 500 ug/L if age is 50 years and less and age × 10 ug/L if age is above 50 years with D-dimer testing (high sensitivity). ^† Pulmonary embolism is confirmed if thrombosis visualized above the subsegmental level. ^‡ Clinical judgement and/or more tests (e.g. lung ventilation/perfusion scintigraphy or leg compression ultrasound) are required in patients with a Wells score ≥ 2. PE, pulmonary embolism.

Figure 2

Diagnosis flowchart for pregnant patients with stable hemodynamic and suspected pulmonary embolism. DVT, deep vein thrombosis; PE, pulmonary embolism.

Figure 3

Pooled efficacy and safety of factor Xa inhibitors compared with low-molecular-weight heparin in patients with cancer associated thrombosis. CI, confidence interval; CRNM, clinically relevant nonmajor; VTE, venous thromboembolism.