Pharmacologic Treatment of Pulmonary Embolism

Acute pulmonary embolism (PE) is a life-threatening condition with a considerable morbidity and mortality. The pharmacologic treatment of PE consists of an initial treatment phase, followed by an acute phase lasting 3–6 months and a chronic or extended phase, aimed for long term prevention of recurrence. The initial phase should be started immediately after the diagnosis is confirmed. We risk stratify the patients based on their clinical presentation, their right ventricle function and their level of cardiac biomarkers. For high-risk patients and for selected patients with intermediate high risk, the treatment is composed of a combination of anticoagulation and thrombolytic therapy (preferably directed locally to the pulmonary artery by a catheter). For lower risk stable patients and for intermediate low risk patients anticoagulation alone is the treatment of choice. The range of anticoagulants consists of the heparins, mostly low molecular weight heparins (LMWH), vitamin K antagonists (VKAs), and the direct oral anticoagulants (DOACs). The pharmacological properties of the different agents are presented in this chapter with their advantages in different clinical settings. The decision about extended duration therapy is based on the balance between the risk for recurrence and the bleeding risk. The choice of a specific anticoagulant, tailored according to the patient's characteristics, co-morbidities, and preferences.