Management of pulmonary embolism: state of the art treatment and emerging research.

opinion statementPulmonary embolism is one of the most important causes of morbidity and mortality in cardiovascular medicine and demands a circumscribed algorithmic treatment approach (Fig. 1). Anticoagulation should be triggered by a high clinical probability and continued based on urgent definitive imaging. Our assessment then continues with evaluation of the clinical severity of the pulmonary embolism to determine whether the patient will benefit from thrombolysis or not. We usually reserve this option for cases of massive pulmonary embolism (sustained hypotension, pulselessness, or persistent profound bradycardia) or patients with a low cardiopulmonary reserve and categorical signs of right ventricle failure. At this juncture, renal function, a diagnosis of active cancer, calculated bleeding risk, and estimated patient compliance will help us gravitate toward specific agent selection for subsequent anticoagulation management. While rivaroxaban is an attractive oral therapy option, it is not an appropriate choice for patients with significant renal disease; patients with cancer are better treated with low molecular weight heparin when possible. Warfarin anticoagulation continues to be a well-known, valid, and cost-effective treatment option. At the end of the primary treatment we assess each patient for the likelihood of thromboembolism recurrence, which will be highest among those patients with idiopathic events or those with cancer-associated thrombosis. We favor prolonged anticoagulation in these scenarios. In addition, we strongly advocate periodic scheduled follow up of patients on long-term anticoagulation for secondary prophylaxis to re-evaluate their bleeding and recurrence risk. We understand both of these extremes are in a dynamic balance, and likewise so should be the anticoagulation directives. As we learn more about recurrence and bleeding prediction, we foresee a personalized approach in which the anticoagulant agent for each patient will be narrowly chosen based on their specific performance.