Treatment for Pulmonary Embolism: Anticoagulation Selection and Duration

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of morbidity and mortality. Parenteral and oral anticoagulant therapies have emerged as the mainstay of therapeutic treatment options for the management of PE. The introduction of direct acting oral anticoagulants (DOACs) has revolutionized inpatient and outpatient management of VTE, where historically options were limited to parenteral agents and vitamin K antagonists (VKAs). Current day parenteral options include intravenous unfractionated heparin, intravenous direct thrombin inhibitors, subcutaneous low molecular weight heparin, and subcutaneous fondaparinux. Oral anticoagulation options include DOACs and VKAs. Select patient populations at high risk for clinical failure or hemorrhagic events, including morbidly obese, frail, elderly, or severe kidney dysfunction require further investigation into the optimal anticoagulant therapy that balances safety and effectiveness. Anticoagulant choice in these high-risk populations is based on limited data and agent specific pharmacokinetic and pharmacodynamic properties. Furthermore, duration of therapeutic anticoagulation should be individualized for each patient and should include initial and periodic assessment of the presence of transient or persistent risk factors for recurrent VTE. This chapter provides essential information and guidance on the practical management of anticoagulant options for patient-centered approach to treatment and secondary prevention of PE.