Contemporary management of acute pulmonary embolism

Acute pulmonary embolism (PE) is one of the leading causes of in-hospital mortality and the third more frequent cause of cardiovascular mortality. The optimal management of PE patients is a clinical conundrum since the spectrum of PE manifestations varies largely depending on clinical and hemodynamic features. According to international guidelines, systemic thrombolysis ranks as first-line treatment for high-risk PE complicated by hemodynamic instability. However, a not negligible proportion of PE patients present contraindications to systemic thrombolysis. Among hemodynamically stable patients with right ventricular dysfunction ("intermediate risk" PE), anticoagulation alone remains the standard treatment but is still associated with relevant risk. Novel interventional techniques including catheter-directed thrombolysis, mechanical thrombectomy, and hybrid approaches have been developed to facilitate reperfusion while mitigating the risk of bleeding. In this review, we provide a comprehensive and contemporary overview of pharmacological and interventional treatments for PE, moving from clinical evidence to practical recommendations and future directions.