Pulmonary%20thromboembolism Management

• Patients w/ acute pulmonary embolism (PE) have a high frequency (20-50%) of symptomatic extension of thrombus &/or recurrent venous thromboembolism (VTE) & therefore require long-term anticoagulant treatment
• Treatment w/ oral anticoagulant is the preferred method of long-term management of most PE patients
• Adjusted doses of unfractionated heparin (UFH)  or low-molecular-weight heparin (LMWH) may be indicated for selected patients in whom oral anticoagulants are contraindicated or impractical

Low-molecular-weight Heparin (LMWH)

• Preferred drug for patients w/ PE & cancer
  
  • Should be used for the 1st 3-6 months of long-term anticoagulant therapy, then continued as oral therapy indefinitely or until cancer has resolved

Oral Anticoagulant

• Duration of anticoagulation is dependent on the type of event & the coexistence of prolonged risk factors:
  
  • PE due to transient or reversible risk factor: Oral anticoagulation is recommended for at least 3 months
  • Unprovoked PE: Oral anticoagulation is recommended for at least 3 months
  • Unprovoked PE (1st episode), w/ low-risk of bleeding & in whom stable anticoagulation can be achieved: Consider long-term oral anticoagulation
  • Unprovoked PE (2nd episode): Long-term treatment is recommended

Risk Factors for Major Bleeding During Anticoagulation

• Age >75 years
• Previous gastrointestinal (GI) bleeding
• Previous noncardioembolic stroke
• Chronic hepatic & renal disease
• Concomitant antiplatelet therapy
• Poor anticoagulant control
• Suboptimal monitoring of therapy
• Comorbid illness

Monitoring During Anticoagulation

• International normalized ratio (INR) should be checked at least weekly during the 1st several weeks of Warfarin therapy
• If stable, monitor every 2 weeks then every 4 weeks, but not >4 weeks
• Target INR is 2.5 for most patients & 3.0 for patients w/ recurrent VTE