Pulmonary Embolism: Management

Key points

• Haemodynamically unstable PE (hypotension, shock, cardiac arrest) → systemic thrombolysis (e.g. IV alteplase) is first-line · use unfractionated heparin when thrombolysis is being considered, or in severe renal impairment · BTS: may be given on clinical grounds alone if cardiac arrest is imminent.
• Haemodynamically stable PE: offer apixaban or rivaroxaban first-line — neither needs initial parenteral heparin. This replaces the older LMWH/fondaparinux-then-warfarin pathway.
• If apixaban or rivaroxaban are unsuitable: LMWH for at least 5 days followed by dabigatran or edoxaban, or LMWH with a vitamin K antagonist until INR ≥ 2.0 on two consecutive readings.
• Risk-stratify with PESI or simplified PESI (or Hestia criteria) — low-risk PE can be treated as an outpatient provided follow-up and support are in place.
• Duration: at least 3 months · provoked with a resolved risk factor, usually stop at 3 months · unprovoked, consider continuing after weighing recurrence against bleeding risk.
• Active cancer: a DOAC is now first-line for most patients — replacing the older blanket LMWH for 6 months · recurrent VTE despite adequate anticoagulation: consider an IVC filter only after other options have been considered.

Decision points in this pathway

• Haemodynamically unstable PE (hypotension, shock, cardiac arrest)?
• Low risk on PESI / simplified PESI (or Hestia criteria)?
• Unprovoked PE (no transient provoking factor such as surgery, trauma or immobility)?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.