Oral warafin therapy is started on day 1 and adjusted to achive

an international normalized ratio of 2 to 3. Heparain or

fondaparinux therapy can be discontinued after 5 days if the
international normalized ratio is 2 or above for at least 24 hours
with warfarin. Oral anticoagulation should continue for at least 3
month, but some pasient (those with unprovoked first PE/deep
venous thrombosis or recurren unprovoked PE/deep venous
thrombosis) may have indication for longer therapy unless there
is a high risk of bleeding. For pasient with underlying
malignancy, extended therapy with LMWH is suggested over
warfain, but the choice of agent may be influenced by costs,
tolerance of injaction, and need for monitoring. In pasient who
receive long-trem anticoagulant treatment, the risk/benefit ratio
of continuing such treatment should be reassessed at regular
intervals.

Systemic thrombolysis for PE may improve pulmonary arterial

hemodynamics, lung perfusion, and right ventricular function,
but the quality of evidence suggesting improved mortality is
low. The use of thrombolytic agents at treatment of PE should
take into account the patient`s hemodynamic status, right
ventricular function, and risk of bleeding. Systemic thrombolytic
therapy is currently suggested for a pasient with acute PE of
hypotension who are at low risk of bleending. Thrombolysis is
not recommended for most hemodynamically stable patients
with PE. Although thrombolysis is suggested for a subgroup of
patients with a high risk of developing hypotension, there are no
validated clinical findings that can be used to identify such
patients. Multiple clinical signs such as tachycardia, decrease in
blood pressure, hypoxemia, evidence of hypoperfusion, and
right ventricular dysfunction can be considered in decision-
making. Tissue plasminogen activator is preferred at a dose of
100 mg infused over a 2-hour period. Streptokinase has also
been used with a loading cloase dose of 250,000 international
units, followed by 100,000 international units each hour for 24
hours. Short administration times are preferred over prolonged
infunsion times. Local administration of a thrombolytic agent
via a catheter is not recommended. Surgical embolectomy or
exraction/fragmentation of the embolus via transvenous
catheters requires specialized expertise not commonly available,
but it can be considered when thrombolysis is absolutely
contraindicated or has failed and when shock is likely to couse
death before thrombolytics can affect clot dissolution.

An inferior vena cava filter should be considered in patients with

pulmonary embolism when
- There is a strong contraindication to anticoagulation
- Emboli recur during anticoagulation
- Bleeding occurs during anticoagulation
Retrievable filters may be an option in some centers. If possible,
anticoagulation for treatment of the embolus should be resumed
as soon as possible after insertion of a filter.