Preemptive Anticoagulation for Patients With Suspected Pulmonary Embolism in the Emergency Department: An International Survey of Emergency Physicians

BACKGROUND: Guidelines recommend therapeutic anticoagulation for select patients with suspected pulmonary embolism (PE) while awaiting confirmatory imaging. International practice regarding preemptive anticoagulation in the emergency department (ED) is not well understood. We aimed to describe emergency physician use of preemptive anticoagulation in patients with suspected PE and identify characteristics associated with its use. METHODS: We conducted an international survey of emergency physicians. The survey was distributed between November 2024 and May 2025. Physicians were asked about use of preemptive anticoagulation, factors associated with use, knowledge of international guidelines, and availability of local protocols. A clinical vignette examined decision making surrounding initiation of preemptive anticoagulation. Multivariable logistic regression models were used to examine factors associated with (1) sometimes/always using preemptive anticoagulation and (2) with use in the vignette. RESULTS: There were 413 responses (27.6% response rate) from 13 countries. Among respondents, 23.1% reported never providing preemptive anticoagulation, 73.9% reported sometimes using it, and 2.9% reported always using it. Over two-thirds of respondents were unaware of recommendations for using preemptive anticoagulation and half reported their institution did not have protocols for preemptive anticoagulation. In multivariable regression, more clinical experience (OR: 1.81, 95% CI: 1.38-2.38), higher self-rated knowledge about PE (OR: 2.05, 95% CI: 1.03-4.06), and more concern for cardiovascular deterioration (OR: 3.21, 95% CI: 1.88-5.49) were positively associated with sometimes/always using preemptive anticoagulation. More concern for bleeding was associated with a lower odds of sometimes or always using preemptive anticoagulation. In the vignette, respondents with institutional protocols for preemptive anticoagulation had higher odds of starting preemptive anticoagulation and those with more concern for bleeding had lower odds of starting it. CONCLUSION: Use of preemptive anticoagulation for patients with suspected PE was low. Most physicians were unaware of guidelines supporting its use and do not have institutional protocols to guide use of preemptive anticoagulation. Implementation and use of institutional protocols may increase guideline-directed preemptive anticoagulation in select patients.