Stable Patients with Confirmed PE

The following should be undertaken for stable patients with confirmed PE:

Oxygen

Oxygen should be administered to any patient with oxygen saturations of <94% on room air (BTS oxygen guidelines, 2008).

Anticoagulation

All patients with confirmed PE require anticoagulation, but there is debate as to the length of time for which anticoagulation is required in pulmonary embolism.

• There is no clear evidence that anticoagulating patients for 6 months is any more beneficial than doing so for 3 months, but the increased risk of bleeding may be important.
• NICE 2020 clinical guideline suggests that all patients should be offered anticoagulation for at least 3 months.
• The decision to continue beyond 3 months needs to be evaluated based on the individuals risk of recurrences (ie provoked or unprovoked) compared to the risk of bleeding.
• If there have been multiple episodes or continuing risk factors such as malignancy lifelong anticoagulation should be recommended.

With the increase in evidence supporting the use of DOAC’s (direct oral anti-coagulants) for the management of PE, most centres have moved away from using Vitamin K antagonists such as warfarin as first line for management of VTE.

NICE recommends the use of either apixaban or rivaroxaban as first line for patient and gives guidance on what agents to use if neither of these are possible in individual patients.

Always use local hospital guidelines when choosing an anticoagulation strategy.

Learning Bite

Fonduparinux, a newer alternative to LMWH, may be considered for certain religious groups (part of the production process of LMWH uses pigs) and patients who have had previous problems with heparin such as thrombocytopenia.