Low Molecular Weight Heparin for 72 Hours Followed by Dabigatran for Acute Intermediate-Risk Pulmonary Embolism. (PEITHO-2)

Inclusion Criteria:

1. Age ≥18 years
2. Objectively confirmed diagnosis of acute PE by multidetector CT angiography, ventilation/perfusion lung scan, or selective invasive pulmonary angiography, according to established diagnostic criteria, with or without symptomatic deep vein thrombosis
3. Absence of hemodynamic collapse, or decompensation, at presentation; Hemodynamic collapse or decompensation

4. Intermediate-risk category of PE severity indicated by a positive (score ≥1) simplified pulmonary embolism severity index (sPESI), in combination with the presence of at least one of the following criteria at presentation:

   • At least one sign of RV pressure overload/dysfunction on CT angiography or echocardiography
   • Signs of myocardial injury as indicated by elevated troponin levels
   • Signs of (RV) failure as indicated by NT-proBNP levels >600 pg/ml at baseline.
5. Ability of the subject to understand the character and individual consequences of the clinical trial; signed and dated informed consent of the subject available before the start of any specific trial procedures

Exclusion Criteria:

1. Pregnancy (a negative serum or urine pregnancy test should be available for women of child-bearing potential before study inclusion) or lactation
2. Women of childbearing potential who do not practice a medically accepted highly effective contraception during the trial and one month beyond
3. History of hypersensitivity to the investigational medicinal product or to any drug with similar chemical structure or to any excipient present in the pharmaceutical form of the investigational medicinal product
4. Participation in another clinical trial during the present clinical trial or within the last three months
5. Medical or psychological condition that would not permit completion of the trial or signing of informed consent
6. Use of a fibrinolytic agent, surgical thrombectomy, interventional (catheter-directed) thrombus aspiration or lysis, or use of a cava filter to treat the index episode of PE
7. Treatment with any therapeutically dosed anticoagulant for more than 48 hours prior to enrolment
8. Need for long-term treatment with a low molecular weight heparin, vitamin K antagonists or NOAC, for an indication other than the index PE episode, or for antiplatelet agents except acetylsalicylic acid at a dosage ≤100 mg/day;
9. Active bleeding or known significant bleeding risk (e.g., gastrointestinal ulcer, malignant neoplasms, injuries or recent surgeries of the brain, spinal cord or eyes, recent intracranial bleedings, known or suspected esophagus varices, aneurysms or intraspinal or intracranial vascular abnormalities)
10. Artificial heart valves requiring treatment with an anticoagulant
11. Renal insufficiency with estimated creatinine clearance <30 ml/min/1.73m2
12. Chronic liver disease with aminotransferase levels two times or more above the local upper limit of normal range
13. Concomitant administration of strong inhibitors of P-glycoprotein like ketoconazole, cyclosporin, itraconazole or dronedarone
14. Unwillingness or inability to adhere to treatment or to the follow-up visits
15. Life expectancy less than 6 months