Contemporary anticoagulation management in pulmonary embolism

Pulmonary embolism (PE) remains a major cause of cardiovascular morbidity and mortality, but the central management question clinicians increasingly face is not whether to anticoagulate, but how to anticoagulate well. Rapid expansion of the evidence base has transformed anticoagulation management from a largely protocol-driven approach into a more individualised and dynamic model of care. Contemporary treatment decisions extend beyond initial drug selection and increasingly require consideration of dose intensity, treatment duration, bleeding phenotype, cancer status, renal function, drug interactions, and evolving thrombotic risk. Direct oral anticoagulants (DOACs) are now established as first-line therapy for most haemodynamically stable patients, while recent studies have refined selection within the DOAC class and challenged traditional assumptions regarding extended therapy. Emerging evidence suggests that some patients with apparently strongly provoked venous thromboembolism may nevertheless benefit from prolonged anticoagulation when enduring prothrombotic risk factors persist. Other studies support selective dose reduction during long-term therapy, while highlighting important limitations of this strategy in obesity. In cancer-associated thrombosis, contemporary trials increasingly support dynamic and phenotype-driven approaches to prolonged anticoagulation rather than fixed-duration treatment paradigms. This review synthesises evolving evidence on anticoagulation management in PE into a practical framework for clinicians involved in longitudinal venous thromboembolism care. Throughout this review, we distinguish established practice supported by contemporary international guidelines from emerging evidence that may refine future management but has not yet been incorporated into guideline recommendations.