title: Managing pulmonary embolism from presentation to extended treatment.
abstract: Pulmonary embolism (PE) remains a major healthcare problem. PE presents with a variety of non-specific symptoms, and confirmation of diagnosis involves the use of clinical risk scores, scanning techniques and laboratory tests. Treatment choice is informed by the risk of sudden death, with high-risk patients recommended to receive thrombolytic therapy or thrombectomy. Patients with less severe presentations are given anticoagulant therapy, traditionally with parenteral heparins in the acute phase of treatment, transitioning to oral vitamin K antagonists (VKAs). The limitations of these agents and the introduction of non-VKA oral anticoagulants challenge this paradigm. To date, clinical studies of four non-VKA oral anticoagulants to treat acute thrombosis have been published, and rivaroxaban is now approved for treatment and prevention of PE (and deep vein thrombosis). Rivaroxaban and apixaban alone, and dabigatran and edoxaban after parenteral anticoagulant induction, were non-inferior to enoxaparin/VKA for the prevention of recurrent venous thromboembolism; the risk of major bleeding was similar with dabigatran and edoxaban and significantly reduced with rivaroxaban and apixaban. Patients with an initial PE are recommended to receive continued anticoagulation for 3 months or longer, depending on individual risk factors, and studies of non-VKA oral anticoagulants have shown a continued benefit for up to 2 years, without a significantly increased risk of major bleeding. Given that the non-VKA oral anticoagulants are given at fixed doses without the need for routine coagulation monitoring, their adoption is likely to ease the burden on both PE patients and healthcare practitioners when longer-term or extended anticoagulation is warranted.
authors.affiliation: Department of Haematological Medicine, King's College Hospital, London, UK. Electronic address: alexander.cohen@kcl.ac.uk.
authors.forename: Alexander T
authors.initials: AT
authors.lastname: Cohen
authors.affiliation: Department of Haematological Medicine, King's College Hospital, London, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Dobromirski
authors.affiliation: Department of Haematological Medicine, King's College Hospital, London, UK.
authors.forename: Meredith M P
authors.initials: MM
authors.lastname: Gurwith
mesh_terms: D000818:Animals; D000925:Anticoagulants / Q000627:therapeutic use*; D006801:Humans; D011651:Pulmonary Artery / Q000187:drug effects / Q000473:pathology; D011655:Pulmonary Embolism / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control; D015912:Thrombolytic Therapy / Q000379:methods
chemical_list: D000925:Anticoagulants
keywords: ACC; ACCP; ASA; Acute; American College of Cardiology; American College of Chest Physicians; Anticoagulant; CI; CT; CTPA; CTPH; CUS; CXR; CrCl; DVT; ELISA; ESC; European Society of Cardiology; HR; INR; IVC; LMWH; Long-term; OAC; PE; PESI; Pulmonary Embolism Severity Index; Pulmonary embolism; RR; RV; Treatment; UFH; V/Q; VKA; VTE; acetylsalicylic acid; bid; chest X-ray; chronic thromboembolic pulmonary hypertension; compression ultrasonography; computed tomography; computed tomography pulmonary angiography; confidence interval; creatinine clearance; deep vein thrombosis; enzyme-linked immunosorbent assay; hazard ratio; i.v; inferior vena cava; international normalised ratio; intravenous; low molecular weight heparin; od; once daily; oral anticoagulant; pulmonary embolism; recombinant tissue plasminogen activator; relative risk; right ventricular; rtPA; s.c; subcutaneous; twice daily; unfractionated heparin; venous thromboembolism; ventilation-perfusion scintigraphy; vitamin K antagonist