How should I manage a patient with a confirmed pulmonary embolism in terms of anticoagulation therapy?

For a patient with confirmed pulmonary embolism (PE), anticoagulation therapy should be initiated and managed as follows:

• First-line oral anticoagulants: Offer either apixaban or rivaroxaban as initial treatment for confirmed proximal PE, unless contraindicated by comorbidities or clinical features ².
• If apixaban or rivaroxaban are unsuitable: Use low molecular weight heparin (LMWH) for at least 5 days followed by dabigatran or edoxaban, or LMWH concurrently with a vitamin K antagonist (VKA) for at least 5 days until the international normalized ratio (INR) is ≥2.0 in two consecutive readings, then continue VKA alone ².
• Baseline blood tests: Before or at the start of anticoagulation, carry out full blood count, renal and hepatic function, prothrombin time (PT), and activated partial thromboplastin time (APTT). Do not delay treatment while awaiting results but review and act on them within 24 hours ¹,².
• Duration of treatment: Offer anticoagulation for at least 3 months. Further duration depends on clinical assessment and secondary prevention needs ².
• Special populations: For patients with haemodynamic instability, continuous unfractionated heparin (UFH) infusion and consideration of thrombolytic therapy is recommended ¹,². For those with renal impairment, dose adjustments and choice of anticoagulant should follow specialist advice and local protocols ².
• Patient information and monitoring: Provide patients with an anticoagulant alert card and verbal and written information about their treatment, including duration, adverse effects, interactions, monitoring, and when to seek help ¹.