Unsolved issues in the treatment of pulmonary embolism

The three most controversial and unsolved issues in the treatment of pulmon ary embolism (PE) are: (1) the role of thrombolysis, (2) the role of low mo lecular weight heparin and length of hospital stay, and (3) the optimal dur ation of anticoagulation. The trend is to use thrombolysis more frequently, to administer low molecular weight heparin and shorten the hospitalization duration in low-risk patients, and to give prolonged courses of anticoagul ation. with warfarin. PE thrombolysis appears most beneficial in patients a t high risk of adverse clinical outcomes in whom the potential hazards of b leeding can be justified by the danger of conservative management with anti coagulation alone. With respect to utilizing low molecular weight heparin a s a way of shortening the duration of hospitalization, there are no data to warrant this approach. The current FDA mandate for symptomatic PE patients is to administer intravenous unfractionated heparin administered as a brid ge to therapeutic warfarin. Finally, the optimal duration of anticoagulatio n following acute PE remains mired in controversy. Despite the high rate of recurrent venous thrombosis after discontinuation of anticoagulation, ther e are currently insufficient data to recommend indefinite warfarin therapy. (C) 2001 Elsevier Science Ltd. All rights reserved.