Optimizing anticoagulant therapy in the management of pulmonary embolism

Pulmonary embolism (PE) continues to command a high price in terms of mortality and recurrence, despite full-dose initial anticoagulation and long-term warfarin therapy. Embolectomy, thrombolysis, and vena cava filters may be life saving in patients with massive PE and cardiogenic shock, but their use in other groups remains controversial. Recent progress has been made in identifying key markers of a poor prognosis; these markers may assist in tailoring treatment to patient risk. In particular, right ventricular dysfunction, detected using echocardiography, may portend an ominous prognosis for patients without hemodynamic instability. Thrombolysis may be beneficial in this group, although concerns about bleeding risk remain to be clarified. Low molecular weight heparins (LMWHs) have recently been shown to be as effective as unfractionated heparin in the initial treatment of PE. One agent has now received a limited approval from the United States Food and Drug Administration for use in certain low-risk patients, mostly those with asymptomatic PE in the presence of concomitant deep-vein thrombosis. Although enoxaparin for PE treatment is currently licensed for therapy exclusively in the hospital setting, brief hospitalization or home treatment for nonmassive PE may be possible in the future. Expert management of long-term warfarin therapy is also crucial to optimize clinical outcomes. Recognition of potential causes of excessive anticoagulation and the use of self-monitoring by patients may improve the efficacy and safety of long-term warfarin administration.