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6.7 Recommendations for acute-phase treatment of intermediate- or low-risk pulmonary embolism

Recommendations Classa Levelb

Initiation of anticoagulation Initiation of anticoagulation is recommended without delay in patients with high or intermediate clinical probability of PE,c while diagnostic workup is in progress. I C If anticoagulation is initiated parenterally, LMWH or fondaparinux is recommended (over UFH) for most patients.262,309311 I A When oral anticoagulation is started in a patient with PE who is eligible for a NOAC (apixaban, dabigatran, edoxaban, or rivaroxaban), a NOAC is recommended in preference to a VKA.260,261,312314 I A When patients are treated with a VKA, overlapping with parenteral anticoagulation is recommended until an INR of 2.5 (range 2.03.0) is reached.315,316 I A NOACs are not recommended in patients with severe renal impairment,d during pregnancy and lactation, and in patients with antiphospholipid antibody syndrome.260,261,312314 III C Reperfusion treatment Rescue thrombolytic therapy is recommended for patients with haemodynamic deterioration on anticoagulation treatment.282 I B As an alternative to rescue thrombolytic therapy, surgical embolectomye or percutaneous catheter-directed treatmente should be considered for patients with haemodynamic deterioration on anticoagulation treatment. IIa C Routine use of primary systemic thrombolysis is not recommended in patients with intermediate- or low-risk PE.c,f 179 III B

CrCl = creatinine clearance; INR = international normalized ratio; LMWH = low-molecular weight heparin; NOAC(s) = non-vitamin K antagonist oral anticoagulant(s); PE = pulmonary embolism; UFH = unfractionated heparin; VKA = vitamin K antagonist. aClass of recommendation. bLevel of evidence. cSee Table 8 for definition of the PE severity and PE-related risk. dDabigatran is not recommended in patients with CrCl <30 mL/min. Edoxaban should be given at a dose of 30 mg once daily in patients with CrCl of 15 - 50 mL/ min and is not recommended in patients with CrCl <15 mL/min. Rivaroxaban and apixaban are to be used with caution in patients with CrCl 15 - 29 mL/min, and their use is not recommended in patients with CrCl <15 mL/min. eIf appropriate expertise and resources are available on-site. fThe risk-to-benefit ratios of surgical embolectomy or catheter-directed procedures have not yet been established in intermediate- or low-risk PE. 6.9 Recommendations for inferior vena cava filters

Recommendations Classa Levelb

IVC filters should be considered in patients with acute PE and absolute contraindications to anticoagulation. IIa C IVC filters should be considered in cases of PE recurrence despite therapeutic anticoagulation. IIa C Routine use of IVC filters is not recommended.302304 III A

IVC = inferior vena cava; PE = pulmonary embolism. aClass of recommendation. bLevel of evidence.

6.8 Recommendations for multidisciplinary pulmonary embolism teams

Recommendation Classa Levelb

Set-up of a multidisciplinary team and a programme for the management of high- and (in selected cases) intermediate-risk PE should be considered, depending on the resources and expertise available in each hospital. IIa C

PE = pulmonary embolism. aClass of recommendation. bLevel of evidence.

6.10 Recommendations for early discharge and home treatment

Recommendation Classa Levelb

Carefully selected patients with low-risk PE should be considered for early discharge and continuation of treatment at home, if proper outpatient care and anticoagulant treatment can be provided.c 178,206,317319 IIa A

PE = pulmonary embolism. aClass of recommendation. bLevel of evidence. cSee section 7 and Figure 6 for further guidance on defining low-risk PE and decision-making. Downloaded from academic.oup.com/eurheartj/article/41/4/543/5556136 by guest on 07 October 2026