1. Risk stratification of PE involves clinical assessment, evaluation of right ventricular size and function, and analysis of cardiac biomarkers. 2. Management of normotensive PE with normal RV involves anticoagulation alone while hypotensive PE requires primary therapy like thrombolysis or embolectomy. 3. Anticoagulation options include parenteral anticoagulants bridging to warfarin or novel oral anticoagulants like Rivaroxaban. LMWH is preferred in pregnant women. The duration of anticoagulation depends on whether the PE was provoked or unprovoked.

1. DR. Md SHAHID IQUBAL
DEPTT. OF MEDICINE, NMCH

2. TREATMENT OF PE
 RISK STRATIFICATION:
• 3 KEY COMPONENT OF RISK STRATIFICATION-
1. Clinical assessment (hemodynamically stable or not)
2. Right ventricular size and function.
3. Analysis of elevated cardiac biomarkers.

3. MANAGEMENT STRATEGY FOR
ACUTE PE
RISK
STRATIFY
NORMOTENSI
ON PLUS
NORMAL RV
SECONDARY
PREVENTION
ANTICOAGULA
TION ALONE
IVC
FILTER
NORMOTENSIVE
PLUS RV
HYPOKINESIA
INDIVIDUAL
THERAPY
HYPOTENSION
PRIMARY
THERAPY
ANTICOAGULA
TION PLUS
THROMBOLYSI
S
EMBOLECTOM
Y, CATHETER
OR
SURGERICAL

4. MANAGEMENT STRATEGY FOR
ACUTE PE
 ANTICOAGULATION:
 There are 3 options:-
1. Conventional strategy of parenteral therapy bridge to
warfarin.
2. Parenteral therapy bridge to novel oral anticoagulant.
3. Oral anticoagulation with Rivaroxaban or Apixaban( anti
Xa agent).
 3 heparin based parenteral anticoagulants are
available: UFH, LMWH, FONDAPARINUX.

5. MANAGEMENT STRATEGY FOR
ACUTE PE
 UFH:
 Initial dose is bolus of 80 U/kg followed by an initial
infusion rate 18 U/kg/hr.
 Dosed to a targetted aPTT of 60-80 sec.
 Major advantage- its short half life.

6. MANAGEMENT STRATEGY FOR
ACUTE PE
 LMWH:
 greater bioavailability
 more predictable dose response
 no monitoring or dose- adjustment needed, except in
renal impairment.
 LMWH is the first choice in pregnant women

7. MANAGEMENT STRATEGY FOR
ACUTE PE
Fondaparinux:
 anti Xa pentasaccharide administered as
weight-based once daily S.C injection in a
prefilled syringe.
 Dose is 5mg once daily S.C for <50kg bw.
And 7.5 mg for >50kg bw.
 No lab monitoring is required.
 It does not cause heparin-induced
thrombocytopenia
 Dose must be adjusted in renal
dysfunction.

8. MANAGEMENT STRATEGY FOR
ACUTE PE
WARFARIN:
 vit K antagonist(VKA).
 In an average size adult, it is started in a dose of 5mg
daily. In the 1st 5 days, overlapping UFH, LMWH or
fondaparinux should be given.
 Targetted INR is 2-3.
 INR monitoring should occur frequently during the
first month of therapy
twice weekly for 1 to 2 weeks, then weekly for 2
weeks, then less frequently

9. Novel oral anticoagulants.
 Administered in a fixed dose.
 Establish anticoagulation within hours of ingestion.
 Require no lab monitoring.
 Few interactions.
Rivaroxaban: factor Xa inhibitor. Approved for Rx of
acute PE as monotherapy without a parenteral
bridging anticoagulant. Dose is 15mg BD for 3 weeks
followed by 20mg OD.
 Apixaban, Dabigatran, Edoxaban are likely to be
approved.

10. Complication of anticoagulants
 The most serious adverse effect of anticoagulation is
hemorrhage.
 For life-threatening or intracranial hemorrhage due to
heparin or LMWH, protamine sulfate can be given.
 Heparin-induced thrombocytopenia is more common with
UFH.
 DOC for HIT is direct thrombin inhibitor (BIVALIRUDIN)
 Major bleeding from warfarin is best managed with
prothrombin complex concentrate.
 In less serious bleeding, fresh-frozen plasma or intravenous
vitamin K can be used.

11. Duration of anticoagulation
 For an initial episode of provoked(surgery, trauma,
estrogen, indwelling catheter) PE, 3 to 6 month of
anticoagulation are considered sufficient.
 For pt with cancer and VTE, LMWH can be prescribed
as monotherapy and continue anticoagulation
indefinitely unless the pt become Cancer-free.
 For unprovoked PE, anticoagulation for indefinite
duration with a target INR of 2-3;

12. IVC FILTER
 INDICATIONS:
1. Active bleeding in which
anticoagulation therapy is
contraindicated
2. Recurrent venous thrombosis
despite intensive
anticoagulation.

13. FIBRINOLYSIS
 INDICATIONS:
 Only FDA approved indication is Massive Pulmonary embolism
 Regimen is 100mg of RtPA administered as a continuous peripheral I.V
infusion over 2 hours.
 The sooner the thrombolysis, the more effective it is.
 Can be used for atleast 14 days after the PE has occurred.
 Contraindication:
 Recent surgery
 Trauma
 history of cerebrovascular hemorrhage at any time, a nonhemorrhagic
 stroke or other cerebrovascular event within the past year,
 Marked hypertension (systolic arterial pressure >180 mmHg and/or a
diastolic pressure >110 mmHg,
 suspicion of aortic dissection, and
 active internal bleeding

14. Catheter embolectomy
 often combined with local
thrombolytic therapy.
 Indicated in that pt in which
systemic thrombolytic therapy is
contraindicated.
 The dose of alteplase can be
markedly reduced, usually to a
range of 20 to 25 mg (in
peripheral intravenous systemic
dose is 100 mg.)

15. PROPHYLAXIS OF PE
 PE is the most common preventable cause of death
among hospitalized patients.
 Low-dose UFH or LMWH is the most common form of
in-hospital prophylaxis
 Duration of prophylaxis is an important consideration.
 Long-duration prophylaxis is not effective and safe in
medically ill patients after hospital discharge.
 For hip replacement or extensive cancer surgery, the
duration of prophylaxis is usually at least 1 month.

16. PROPHYLAXIS OF PE
Some prophylaxis strategy are as follow-
 -
High-risk nonorthopedic
surgery
UF heparin 5000 units SC bid or tid
Enoxaparin 40 mg daily
Cancer surgery, including
gynecologic cancer surgery
Enoxaparin 40 mg daily, consider 1 month of
prophylaxis
Major orthopedic surgery Warfarin (target INR 2.0–3.0)
Enoxaparin 40 mg daily
Fondaparinux 2.5 mg daily
Aspirin 81–325 mg daily
Intermittent pneumatic compression (with or
without pharmacologic prophylaxis)
Medically ill patients, especially
if immobilized
Unfractionated heparin 5000 units bid or tid
Enoxaparin 40 mg daily

17. Take home message
 Treatment should be started as soon as diagnosis is
confirmed, with
 Anticoagulants alone/ IVC filter.
 Anticoagulants with fibrinolytics.
 Interventional methods such as Embolectomy.
 LMWH is the first choice of anticoagulant in
pregnant women
 The most serious adverse effect of anticoagulation is
hemorrhage.
o PE is the most common preventable cause of death
among hospitalized patients.

18. Thank you…