Pulmonary embolism (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • Highland HSCP only
  • Primary and Secondary Care
  • Adults only

Acute pulmonary embolism (PE) is a common and sometimes fatal disease with a variable clinical presentation. This guideline details the investigation, diagnosis, management and follow up of patients with PE.

Suspected PE: Investigations

Simplified Geneva
Previous DVT/PE 1
HR 75 to 94 1
HR ≥95 2
Surgery or fracture within the last month 1
Haemoptysis 1
Active Cancer 1
Unilateral lower limb pain 1
Pain on deep vein palpation 1
Age ≥65 1

Confirmed PE: Risk stratification

sPESI: Simplified PESI
Age >80 1
Cancer 1
Chronic Heart Failure 1
HR ≥110 1
Systolic BP <100 1
Arterial saturation <90% 1

Thrombolysis for haemodynamically unstable patients

If NO contraindications to thrombolysis, give alteplase:

  • Weight ≥65kg: 100mg over 2 hours, administered as:
    • 10mg IV bolus over 1 to 2 min, THEN
    • 90mg IV infusion over 2 hours
  • Weight <65kg: 1.5mg/kg over 2 hours, administered as:
    • 10mg IV bolus over 1 to 2 min, THEN
    • Remainder of dose as IV infusion over 2 hours

Injectable Medicines Guide access:

Absolute contra-indications to thrombolysis include:

  • Intracranial neoplasm
  • Recent (<2 months) intracranial or spinal surgery or trauma
  • History of a haemorrhagic stroke
  • Active bleeding or bleeding diathesis (eg, severe thrombocytopenia)
  • Treatment with anticoagulant
  • Or non-haemorrhagic stroke, within the previous three months.

Relative contra-indications to thrombolysis include:

  • Severe uncontrolled hypertension (systolic blood pressure >200 mmHg or diastolic blood pressure >110 mmHg)
  • Non-haemorrhagic stroke more than three months prior
  • Surgery within the previous 10 days
  • Pregnancy
  • Haemorrhagic or ischaemic stroke in preceding 6 months

Complete drug information: Actilyse 10 mg powder and solvent for solution for injection and infusion - Summary of Product Characteristics

Anticoagulation for haemodynamically stable patients

Direct oral anticoagulants (DOACs)

First-line option:

Apixaban

  • 10mg twice daily for 7 days, THEN
  • 5mg twice daily for at least 3 months (See: Treatment duration and follow-up)

Detailed drug information: Apixaban 5mg Film-Coated Tablets - Summary of Product Characteristics (SmPC)

Second-line options:

Rivaroxaban

  • 15mg twice daily for 21 days, THEN
  • 20mg once daily for at least 3 month (See: Treatment duration and follow-up)

Detailed drug information: Xarelto 15mg film-coated tablets - Summary of Product Characteristics (SmPC)

Dabigatran and edoxaban.

  • Note: requirement for 5 days of treatment dose low molecular weight heparin before initiating edoxaban for PE.
  • See SPC’s for detailed prescribing information.

Notes: 

  • All patients commenced DOAC should have medications reviewed:
    • Antiplatelets: consider stopping, unless clear indication to continue antiplatelet in combination with DOAC. Consider discussing with Cardiology, where appropriate.
    • NSAID’s: bleeding risk, avoid where possible.
  • Check detailed drug interaction information: Medicines Complete — Stockley's Interactions Checker
  • All patients initiated on DOAC should receive verbal and written information prior to discharge, see: DOAC Counselling Tool (NHS Highland intranet access required)

DOAC contra-indicated or unsuitable at present:

Low Molecular Weight Heparin (LMWH):

Enoxaparin

  • CrCl ≥30mL/min AND low risk of recurrence:
    1.5mg/kg once daily by subcutaneous injection
  • CrCl ≥30mL/min AND additional risk factors (eg, obesity, cancer, recurrent VTE, symptomatic PE):
    1mg/kg twice daily (12 hourly) by subcutaneous injection
  • CrCl <30mL/min:
    1mg/kg once daily by subcutaneous injection

Maximum initiation dose of enoxaparin is 120mg. In patients who weigh >120kg, use 120mg twice daily (provided CrCl >30mL/min), and seek specialist haematology advice +/- monitoring of Xa levels.

Treatment Duration and Follow-Up

Treatment Duration

Provoked PEs (transient/reversible risk factor)

  • Discontinue anticoagulation after 3 months (6 months in active cancer)

Unprovoked or recurrent PEs:

  • Continue anticoagulation for at least 6 months and refer to PE clinic

Follow-up

Patients who should be referred to the PE service for follow-up include:

  • All patients under the age of 50 with PE
  • All unprovoked PE
  • Recurrent PE
  • All intermediate-high and high risk PE, as determined by the Risk Stratification above

Treatment duration >6 months may be appropriate for high risk / recurrent PE patients. Final decision will be made at PE clinic.

Pregnancy

Investigation and management of PE in pregnancy falls outwith these guidelines and they are not applicable. Please contact obstetrics / gynaecology.

Referral form

Pulmonary Embolism service referral form (NHS Highland intranet access required). 

Editorial Information

Last reviewed: 27/06/2024

Next review date: 30/06/2027

Author(s): Departments of Respiratory & Haematology.

Version: 1.1

Approved By: TAMSG of the ADTC

Reviewer name(s): Dr H Said, Consultant Respiratory Physician.

Document Id: TAM635