Intermediate-high Risk Pulmonary Embolism Research Articles

In-hospital and short-term predictors of mortality in patients with intermediate-high risk pulmonary embolism.

Introduction: The aim of this study was to evaluate the in-hospital and short-term predictive factors of mortality in intermediate-high risk acute pulmonary embolism (PE) patients with right ventricle (RV)dysfunction and myocardial injury. Methods: In this retrospective study, the medical records of 187 patients with a diagnosis of intermediate high risk acute PE were evaluated. A contrast-enhanced multi-detector pulmonary angiography was used to confirm diagnosis in all cases. All-cause mortality was determined by obtaining both in hospital and 30 days follow-up data of patients from medical records. Results: During the in-hospital stay (9.5±4.72 days), 7 patients died, resulting in an acute PE related in-hospital mortality of 3.2%. Admission heart rate (HR), (Odds ratio (OR), 1.028 95% Confidence interval (CI), 0.002-1.121; P = 0.048) and blood urea nitrogen (BUN) (OR, 1.028 95% CI, 0.002-1.016; P = 0.044) were found to be independent predictors for in-hospital mortality in a multi variate logistic regression analysis. In total, 32 patients (20.9%) died during 30 days follow-up.The presence of congestive heart failure (OR, 0.015, 95%CI, 0.001-0.211; P = 0.002) and dementia (OR, 0.029, 95%CI,0.002-0.516; P = 0.016) as well as low albumin level (OR, 0.049 95%CI, 0.006-0.383; P = 0.049) were associated with 30 days mortality. Conclusion: HR and BUN were independent predictors of in-hospital mortality and the presence of congestive heart failure, dementia, and low albumin levels were associated with higher 30 days mortality.

Early prescription of direct oral anticoagulants for acute intermediate-high risk pulmonary embolism

The use of direct oral anticoagulants (DOACs) for the early treatment of intermediate-high risk pulmonary embolism (PE) is poorly described. The aims of the present study were to describe clinical patterns and associated risk of adverse events between early and late DOAC prescription after admission for intermediate-high risk PE. We used a prospective regional multicenter registry including all consecutive hemodynamically stable PE patients stratified as intermediate-high risk with right heart strain on cardiac imaging and elevation of cardiac biomarkers. Early DOAC group was defined as a prescription < 72 h after admission, and late DOAC group was defined as a prescription between 72 h and 7 days. Efficacy and safety outcomes were evaluated at 30 days and 6 months. Among 477 patients admitted with an intermediate-high risk PE between 10/2012 and 12/2017, 209 patients were treated with DOACs within the acute phase: early DOAC group was composed of 68 patients (32.5%) and late DOAC group of 141 patients (67.8%). There was no significant difference in baseline characteristics between groups. The rates of efficacy and safety outcomes were similar between patients who were treated early with a DOAC and those who received a late strategy with a prolonged heparin lead-in. Hospital length of stay was shorter in the early DOAC group (6.0 ± 3.6 days vs. 8.2 ± 6.8 days, P = 0.01). Our results might suggest that, if a DOAC is selected for intermediate-high risk PE treatment, it could be prescribed early after admission.

First year experience of a pulmonary embolism response team with comparisons of outcomes between catheter directed therapy versus standard anticoagulation

ABSTRACTObjectives: The Pulmonary Embolism Response Team (PERT) model is now widely adopted in many institutions to provide multidisciplinary care for patients with acute pulmonary embolism (PE). However, descriptive experiences of PERT operations and studies on clinical outcomes remain limited.Methods: We performed a retrospective review of PERT activations at an academic tertiary care center, with secondary aims to study outcomes associated with performing catheter directed therapies (CDT).Results: The intermediate high-risk PE category was most frequent (n = 40, 76.9%) among the 52 total cases evaluated during the study period. There was one in-hospital mortality, associated with hospice admission for a non-PE diagnosis. Six patients (11.5%) experienced a bleeding complication of any severity. Anticoagulation (AC) alone was recommended in 30 patients (57.7%) and CDT was performed in 16 patients (30.8%). There were no significant differences in patient characteristics or disease severity between patients in the AC group versus the CDT group, except for a higher prevalence of malignancy in the AC group (p = 0.037). Patients who underwent CDT demonstrated a lower, albeit non-significant, median intensive care unit (ICU) length of stay (LOS) (3 vs. 4 days, p = 0.34) and hospital LOS (4 vs. 5 days, p = 0.25), as compared to patients receiving AC alone. Bleeding rates were similar between the two groups (6.7% vs. 6.3%, p = 1.0).Conclusions: Adoption of the PERT model at an academic tertiary care center was associated with acceptably low rates of mortality and bleeding, similar to other published studies. Performing CDT in select patients under PERT consultation may be associated with shorter ICU and hospital LOS; however, larger studies are needed to validate this finding.

Intermediate-High Risk Pulmonary Embolism.

Limited information exists about the prevalence, management, and outcomes of intermediate-high risk patients with acute pulmonary embolism (PE). In a prospective cohort study, we evaluated consecutive patients with intermediate-high risk PE at a large, tertiary, academic medical center between January 1, 2015 and March 31, 2019. Adjudicated outcomes included PE-related mortality and a complicated course through 30 days after initiation of PE treatment. Repeat systolic blood pressure (SBP), heart rate (HR), brain natriuretic peptide (BNP), and cardiac troponin I (cTnI) measurements, and echocardiography were performed within 48 hours after diagnosis. Among 1,015 normotensive patients with acute PE, 97 (9.6%) had intermediate-high risk PE. A 30-day complicated course and 30-day PE-related mortality occurred in 23 (24%) and 7 patients (7.2%) with intermediate-high risk PE. Seventeen (18%) intermediate-high risk patients received reperfusion therapy. Within 48 hours after initiation of anticoagulation, normalization of SBP, HR, cTnI, BNP, and echocardiography occurred in 82, 86, 78, 72, and 33% of survivors with intermediate-high risk PE who did not receive immediate thrombolysis. A complicated course between day 2 and day 30 after PE diagnosis for the patients who normalized SBP, HR, cTnI, BNP, and echocardiography measured at 48 hours occurred in 2.9, 1.4, 4.5, 3.3, and 14.3%, respectively. Intermediate-high risk PE occurs in approximately one-tenth of patients with acute symptomatic PE, and is associated with high morbidity and mortality. Normalization of HR 48 hours after diagnosis might identify a group of patients with a very low risk of deterioration during the first month of follow-up.

P5591Efficacy and safety of lower dose slow infusion of t-PA for intermediate-risk pulmonary embolism patients with risk for bleeding

Abstract Background Current guidelines do not recommend thrombolytic therapy for the treatment of intermediate-risk pulmonary embolism (PE) because of the tight balance between the benefit and safety with classic protocols. Aim The aim of this study was to compare the new thrombolytic protocol with lower-dose slow-infusion (LDSI) of tissue plasminogen activator (tPA) to classic 2-hours tPA infusion protocol or no-reperfusion in patients with intermediate-high risk PE with higher bleeding risk regarding 30-day efficacy and safety. Methods Among 849 patients with PE from the Serbian multicenter registry, 469 patients who fulfilled criteria for intermediate-risk PE were involved in the study. After propensity score matching 425 patients [263 (61.9%), 99 (23.3%) and 63 (14.8%) were treated with no-reperfusion, classic tPA protocol (100 mg for 2 hours) and LDSI of tPA (2–5 mg/hour either vie local catheter or systemic venous infusion with dose range of 25–50 mg)]. The basic characteristics of patients were well balanced between groups except that patients treated with LDSI of tPA had significantly higher usage of drugs which can be associated to bleeding and more previous bleeding events. Thirty day all-cause and PE-caused mortality and 7-day major bleeding were the main efficacy and safety end-points, respectively. Results All-cause and PE-cause 30-day mortality were 8.7% vs 16.2% vs 1.6% (Log rank p=0.007) and 4.5% vs 11.0% vs 0.0% (Log rank p=0.008) in patients with no-reperfusion, classic tPA protocol and LDSI of tPA protocol, respectively. Major bleeding at 7 days were 2.7% vs 8.1% vs 14.3% (Log rank p=0.001) in patients with no-reperfusion, classic tPA protocol and LDSI of tPA protocol, respectively. There was one fatal intracranial bleeding during catheter infusion of tPA. Conclusion Lower-dose slow-infusion of tPA protocol decreased significantly all-cause and PE-cause mortality at 30-day at the cost of excess of non-fatal major bleeding at 7-day in patients with intermediate-risk PE and higher risk for bleeding. Acknowledgement/Funding None

Low Dose Thrombolysis, Ultrasound Assisted Thrombolysis or Heparin for Intermediate High Risk Pulmonary Embolism

Low Dose Thrombolysis, Ultrasound Assisted Thrombolysis or Heparin for Intermediate High Risk Pulmonary Embolism

Efficacy and safety of direct oral anticoagulants in intermediate-high risk pulmonary embolism: Results from a multidisciplinary multicenter prospective registry

Data on the initiation of direct oral anticoagulants (DOAC) in patients with intermediate-high risk pulmonary embolism (PE) are lacking. We conducted a prospective multicentre multidisciplinary registry study aimed at: – describing the antithrombotic strategy in real-life practice at the acute phase of intermediate-high risk PE; – assessing efficacy and safety of DOACs vs. standard guidelines-recommended anticoagulation therapy. We enrolled all pts with acute PE hospitalized in 11 participating centers. Intermediate-high risk PE was defined according to the ESC guidelines (hemodynamic stability, echocardiographic signs of RV dysfunction, elevated cardiac biomarkers). Early prescription of DOAC was defined as DOAC-prescription within 24 h after PE diagnosis. Primary outcome was a clinical composite of in-hospital death from any cause and hemodynamic decompensation. All pts were followed for at least 6 months. From 09/2012 to 12/2016, 1056 pts were enrolled. Among 249 (23.6%) intermediate-high risk PE pts, 40 (16.1%) received DOAC and 209 (83.9%) received parenteral anticoagulation in the first 24 h. Active cancer and impaired kidney function were independently related to non-prescription of DOAC. NYHA functional class I or II was the only factor independently associated with use of DOAC. There was no difference between groups in terms of death or hemodynamic decompensation in-hospital (OR 0.18; 95% CI 0.02 to 1.39; P = 0.01). The rate of in-hospital death, hemodynamic decompensation, bleeding, and recurrent PE were also similar. At 6 months, groups did not differ significantly in terms of death, recurrent PE, bleeding, MI or stroke. Our registry suggests that DOACs are quite frequently given as initial treatment in the first 24 h after diagnosis in intermediate-high risk PE pts in clinical practice with promising safety and efficacy profiles compared to standard guidelines-recommended parenteral anticoagulation.

Right ventricular systolic dysfunction in intermediate high-risk pulmonary embolism treated by ultrasound-assisted catheter-directed thrombolysis

For intermediate high-risk pulmonary embolism (PE), the 2014 ESC guidelines support the use of ultrasound-assisted catheter-directed thrombolysis (USAT). These devices provide an optimal balance between a rapid and efficient drug delivery to enable quick right ventricle relief while reducing the risk of bleedings compared to systemic thrombolysis. Some studies show the effect of this procedure on right ventricular (RV) dilatation but few talk about the systolic RV dysfunction, common and responsible for multiple hemodynamic complications. We aim to describe the real-life use and results of USAT procedure in our center compared to the reference treatment with unfractionated heparin alone (UFH). USAT was performed in eligible intermediate high-risk PE patients. Ineligible patients were treated with UFH. Primary outcome was the difference in RV systolic dysfunction (assessed by 3 parameters: visual evaluation with trans thoracic echocardiography (4 severity levels), Tricuspid Annulus Plane Systolic Exclusion (TAPSE) and maximal velocity of tricuspid annulus on tissue Doppler imaging (S’) from baseline to 24 hours. Between September 2017 and October 2018, 20 patients were selected for USAT procedure and 17 were treated with UFH. In the USAT group, 19 patients presented a RV systolic dysfunction at baseline. At 24 hours, only 9 patients presented a persistent RV systolic dysfunction, P = 0.0002. In the UFH group, 13 patients presented a RV systolic dysfunction at baseline and 11 at 24 hours, P = 0.089. The mean improvement in RV systolic function level from baseline to 24 hours was 1.4 ± 0.8 in the USAT group versus 0.29 ± 0.6 in the UFH group, P = 0.02. There was a trend in TAPSE and S’ in favor of the USAT group, P = 0.16 and P = 0.09 respectively. There was no significant bleeding event (Fig. 1). In this cohort, the USAT procedure seems to be efficient in improving the RV systolic function without increasing bleeding event.

Pulmonary Embolism Response Teams: A Novel Approach for the Care of Complex Patients With Pulmonary Embolism.

Pulmonary embolism represents the third most common cause of cardiovascular death in the United States. Reperfusion therapeutic strategies such as systemic thrombolysis, catheter directed therapies, surgical pulmonary embolectomy, and cardiopulmonary support devices are currently available for patients with high- and intermediate-high–risk pulmonary embolism. However, deciding on optimal therapy may be challenging. Pulmonary embolism response teams have been designed to facilitate multidisciplinary decision-making with the goal to improve quality of care for complex cases with pulmonary embolism. Herein, we discuss the current role and strategies on how to leverage the strengths from pulmonary embolism response teams, its possible worldwide adoption, and implementation to improve survival and change the paradigm in the care of a potentially deadly disease.

P3554Efficacy and safety of direct oral anticoagulants in intermediate-high risk pulmonary embolism: results from a multidisciplinary multicenter prospective registry

P3554Efficacy and safety of direct oral anticoagulants in intermediate-high risk pulmonary embolism: results from a multidisciplinary multicenter prospective registry

EFFICACY AND SAFETY OF DIRECT ORAL ANTICOAGULANTS IN INTERMEDIATE-HIGH RISK PULMONARY EMBOLISM: RESULTS FROM A MULTIDISCIPLINARY MULTICENTER PROSPECTIVE REGISTRY

Data on the use of direct oral anticoagulants (DOAC) in patients(pts) with intermediate-high risk pulmonary embolism (PE) are lacking. We conducted a prospective multicentre multidisciplinary registry study (1) to describe the antithrombotic strategy in real-life practice at the acute phase of

A TERTIARY CENTRE EXPERIENCE ON ULTRASOUND-FACILITATED THROMBOLYSIS IN PATIENTS WITH PULMONARY EMBOLISM AT HIGH-RISK OR INTERMEDIATE HIGH-RISK

Ultrasound-facilitated thrombolysis (UFT) is a novel technology with high efficacy and reduced bleeding in acute pulmonary embolism (PE) patients (pts). This study includes our single-center results on UFT for intermediate-high risk and high risk (IHR, HR) PE pts. Our study was based on the

Assessment of coexisting deep vein thrombosis for risk stratification of acute pulmonary embolism

BackgroundIn patients with acute pulmonary embolism (PE), studies have shown an association between coexisting deep vein thrombosis (DVT) and short-term prognosis. It is not known whether complete compression ultrasound testing (CCUS) improves the risk stratification of their disease beyond the recommended prognostic models. MethodsWe included patients with normotensive acute symptomatic PE and prognosticated them with the European Society of Cardiology (ESC) risk model for PE. Subsequently, we determined the prognostic significance of coexisting DVT in patients with various ESC risk categories. The primary endpoint was a complicated course after the diagnosis of PE, defined as death from any cause, haemodynamic collapse, or adjudicated recurrent PE. ResultsAccording to the ESC model, 37% of patients were low-risk, 56% were intermediate-low risk, and 6.7% were intermediate-high risk. CCUS demonstrated coexisting DVT in 375 (44%) patients. Among the 313 patients with low-risk PE, coexisting DVT (46%) did not show a significant increased risk of complicated course (2.8%; 95% confidence interval [CI], 0.8%–7.0%), compared with those without DVT (0.6%; 95% CI, 0%–3.2%), (P = 0.18). Of the 478 patients with intermediate-low risk PE, a complicated course was 14% and 6.8% for those with and without DVT, respectively (P = 0.01). Of the 57 patients that had intermediate-high risk PE, a complicated course occurred in 17% and 18% for those with and without DVT, respectively (P = 1.0). ConclusionsIn normotensive patients with PE, testing for coexisting DVT might improve risk stratification of patients at intermediate-low risk for short-term complications.

Role of echocardiography and cardiac biomarkers in prediction of in-hospital mortality and long-term risk of brain infarction in pulmonary embolism patients

IntroductionThe aim of prospective study was to evaluate the ability of echocardiography and cardiac biomarkers to predict in-hospital mortality and the risk of brain infarction during a 12-month follow-up period (FUP) with anticoagulation in pulmonary embolism (PE) patients. MethodsEighty-eight consecutive acute PE patients (39 men, mean age 63 years) were enrolled; 78 underwent baseline echocardiography and brain magnetic resonance imaging (MRI). After a 12-month FUP, 58 underwent brain MRI. In-hospital mortality and the rates of new ischemic brain lesions (IBL) on MRI with clinical ischemic stroke (IS) events were predicted based on echocardiography (patent foramen ovale presence with right-to-left shunt – PFO/RLS; right/left ventricle diameter ratio – RV/LD; tricuspid annulus plane systolic excursion – TAPSE; tricuspid annulus systolic velocity – ST; pulmonary artery systolic pressure – PASP) and biomarkers results (amino-terminal fragment of brain natriuretic peptide – NT-proBNP and cardiac troponin T – cTnT). ResultsOur series involved 88 patients, of whom 11 (12.5%) presented high-risk PE, 24 (27.3%) intermediate-high risk PE, 19 (21.6%) intermediate-low risk PE and 34 (38.6%) patients had low risk PE.Nine patients (10.2%) died during hospitalization including high-risk PE [6/9 (66.6%)] and intermediate-high-risk PE [3/24 (12.5%)]. cTnT [odds ratio (OR) 4.3; 95% confidence interval 0.59–31.3, P=0.014], NT-proBNP (OR 14.2 [1.5–133.4], P=0.02), RV/LD ≥0.79 (OR 36.6 [4.2–316.4], P=0.001), TAPSE (OR 0.55 [0.34–0.92, P=0.022) and PASP ≥51.5mmHg (OR 33.3 [3.8–292.6], P=0.022) were predictors of in-hospital mortality.Seventeen patients (19.3%) experienced IS (n=8) or new IBL (n=9). On multivariate analysis, PFO/RLS (OR 27.1 [3.0–245.3], P=0.003) and ST ≤14.5cm/s (OR 34.1 [CI 3.4–344.0], P=0.003) were independent predictors of IS and IBL risk. ConclusionsHigh blood troponin T, NT-proBNP, RV dilatation/systolic dysfunction and pulmonary hypertension predicted in-hospital mortality. PFO/RLS presence and ST were predictors of clinically apparent/silent brain infarction.

Prognosis of Pulmonary Embolism with Right Ventricular Dysfunction

Background: Mortality rate of pulmonary embolism (PE) at 3 months is over 15% for the high risk presentation and varies from 3% to 15% for the intermediate-risk presentation. Thrombolysis in intermediate-risk PE remains a matter of debate. Methods: We undertook a retrospective study over a 11-year period including patients with high and intermediatehigh- risk PE, hospitalised in a medical ICU in a University hospital, to assess medium and long-term prognosis. Results: Our series involved 145 patients, of whom 63 presented high risk PE and 82 had an intermediate-highrisk PE. Thirty-six patients (24.8%) died in the intensive care unit (ICU) including high-risk PE: 34/63 (53.9%), of whom 25 after inaugural cardiac arrest (CA); intermediate-high-risk PE: 2/82 (2.4%). On multivariate analysis, high blood lactates (OR: 1.88; IC 95% 1.18-3.02, p=0.0083), resuscitated CA (OR: 12.33; IC 95% 1.1-137.4, p=0.041), low subaortic velocity time integral (VTI) (OR: 9.22, IC 0.38-0.81, p=0.0024) were independent factors of in-ICU mortality. Twenty-seven patients died after ICU discharge. Echocardiographic checks were performed in 63 patients, in which 4 (6.3%) presented a chronic thromboembolic pulmonary hypertension (CTPH). Conclusion: High-risk PE still has a high mortality rate in the ICU especially when revealed by a cardiac arrest. High blood lactates, resuscitated CA, and low subaortic VTI were independent predictive factors of mortality. In our retrospective cohort, long-term prognosis was good with only 4 cases of CTPH. The low mortality observed with anticoagulant-only treatment do not encourage thrombolysis for management of intermediate-high-risk PE patients.

Developing Real-World Patient Pathways in Acute Pulmonary Embolism

This case-based satellite symposium chaired by Prof Konstantinides addressed important and topical aspects of the management of acute pulmonary embolism (PE) with a focus on effective management in a real-world setting. The objectives of the symposium were to provide information and expert guidance on the effective management of a patient with PE from diagnosis and assessment of severity, through to the practical use of non-vitamin K antagonist non-oral anticoagulants (NOACs) and the management of challenging cases found in routine clinical practice. Following Prof Konstantinides’ introduction, Dr Hughes presented a low-risk PE case and discussed assessment of the severity of PE, the optimisation of hospital care, and the importance of patient discharge protocols and clear integrated management pathways. Dr Jiménez went on to illustrate the use of risk assessment and non-vitamin K antagonist (VKA) therapies through consideration of an intermediate high risk PE case with comorbidities. Finally, Dr Eikelboom presented an unprovoked PE case and discussed the key question of ‘how long is long enough’, emphasising the importance of adequate anticoagulation, both acutely and in prevention of recurrence, and the potential benefits of NOACs. In a final Question and Answer Hub session, the audience were able to participate in a lively case-based discussion.

Risk stratification of patients with acute symptomatic pulmonary embolism.

Patients with acute symptomatic pulmonary embolism (PE) who present with arterial hypotension or shock have a high risk of death (high-risk PE), and treatment guidelines recommend strong consideration of thrombolysis in this setting. For normotensive patients diagnosed with PE, risk stratification should aim to differentiate the group of patients deemed as having a low risk for early complications (all-cause mortality, recurrent venous thromboembolism, and major bleeding) (low-risk PE) from the group of patients at higher risk for PE-related complications (intermediate-high risk PE), so low-risk patients could undergo consideration of early outpatient treatment of PE and intermediate-high risk patients would undergo close observation and consideration of thrombolysis. Clinicians should also use risk stratification and eligibility criteria to identify a third group of patients that should not undergo escalated or home therapy (intermediate-low risk PE). Such patients should initiate standard therapy of PE while in the hospital. Clinical models [e.g., Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI)] may accurately identify those at low risk of dying shortly after the diagnosis of PE. For identification of intermediate-high risk patients with acute PE, studies have validated predictive models that use a combination of clinical, laboratory and imaging variables.

Anticoagulation with rivaroxaban after ultrasound-assisted catheter-directed thrombolysis in patients with intermediate highrisk pulmonary embolism a case series

Background: The optimal treatment for intermediate-high risk pulmonary embolism (PE) is still unclear and challenging. A new method for this entity is ultrasound-assisted catheter directed thrombolysis (USAT). The use of non-vitamin K antagonist anticoagulants (NOAC) is currently not recommended after thrombolysis. In our case series we tried to evaluate the efficacy and safety of NOAC treatment shortly after USAT. Methods and findings: We report five patients with intermediate-high risk pulmonary embolism who were successfully treated with rivaroxaban as post-procedural anticoagulation after USAT. The treatment was tolerated well with rapid clinical improvement and almost complete normalisation of right heart function (reduction of mean right to left ventricular (RV/LV) ratio from 1.22 (range 1.07-1.24) at baseline to 0.87 (range 0.76-1.07) three days after thrombolysis (p = 0.016). We observed one GUSTO moderate bleeding episode and a transient rise in creatinine in one patient, but no other adverse events. After 2.4 days (range 2-4 days), patients were switched from unfractionated heparin to rivaroxaban. Follow up-visit after three months showed normalisation of right heart function (RV/LV ratio 0.69 (range 0.65-0.81), no recurrent thrombotic events and no additional bleeding episodes. Conclusion: In our experience, USAT followed by post-procedural anticoagulation with rivaroxaban appears to be an effective treatment of intermediate-high risk pulmonary embolism.

Anticoagulant treatment for acute pulmonary embolism: a pathophysiology-based clinical approach.

The management of patients with acute pulmonary embolism is made challenging by its wide spectrum of clinical presentation and outcome, which is mainly related to patient haemodynamic status and right ventricular overload. Mechanical embolic obstruction and neurohumorally mediated pulmonary vasoconstriction are responsible for right ventricular overload. The pathophysiology of acute pulmonary embolism is the basis for risk stratification of patients as being at high, intermediate and low risk of adverse outcomes. This risk stratification has been advocated to tailor clinical management according to the severity of pulmonary embolism. Anticoagulation is the mainstay of the treatment of acute pulmonary embolism. New direct oral anticoagulants, which are easier to use than conventional anticoagulants, have been compared with conventional anticoagulation in five randomised clinical trials including >11 000 patients with pulmonary embolism. Patients at high risk of pulmonary embolism (those with haemodynamic compromise) were excluded from these studies. Direct oral anticoagulants have been shown to be as effective and at least as safe as conventional anticoagulation in patients with pulmonary embolism without haemodynamic compromise, who are the majority of patients with this disease. Whether these agents are appropriate for the acute-phase treatment of patients at intermediate-high risk pulmonary embolism (those with both right ventricle dysfunction and injury) regardless of any risk stratification remains undefined.