What is the treatment for pulmonary infarction (pulmonary embolism with infarct)?

From the Guidelines

Treatment of pulmonary infarction should focus on anticoagulation therapy, with initiation of anticoagulation without delay in patients with high or intermediate clinical probability of pulmonary embolism, as recommended by the 2019 ESC guidelines 1. The primary approach involves anticoagulation therapy with heparin (unfractionated heparin or low molecular weight heparin), transitioning to oral anticoagulants like warfarin or direct oral anticoagulants (such as apixaban or rivaroxaban) for at least 3-6 months. Some key points to consider in the treatment of pulmonary infarction include:

• Initiation of anticoagulation without delay in patients with high or intermediate clinical probability of pulmonary embolism, while diagnostic workup is in progress 1
• Use of low molecular weight heparin (LMWH) or fondaparinux as the recommended form of initial treatment for most patients with non-high-risk pulmonary embolism 1
• Transition to oral anticoagulants, with a preference for direct oral anticoagulants (such as apixaban or rivaroxaban) over vitamin K antagonists (VKAs) in patients eligible for them 1
• Consideration of thrombolytic therapy in patients with high-risk pulmonary embolism or those with hemodynamic deterioration on anticoagulation treatment 1
• Monitoring for complications such as pleural effusion or infection, and implementation of preventive measures like early mobilization, compression stockings, and addressing risk factors like immobility or hypercoagulable states. Supplemental oxygen should be provided to maintain oxygen saturation above 92%, and pain management typically includes NSAIDs like ibuprofen or acetaminophen. It is essential to note that the treatment approach may vary depending on the individual patient's risk factors, comorbidities, and clinical presentation, and should be guided by the most recent and highest-quality evidence, such as the 2019 ESC guidelines 1.

From the FDA Drug Label

1.3 Treatment of Pulmonary Embolism

XARELTO is indicated for the treatment of pulmonary embolism (PE).

1.4 Reduction in the Risk of Recurrence of Deep Vein Thrombosis and/or Pulmonary Embolism

XARELTO is indicated for the reduction in the risk of recurrence of DVT and/or PE in adult patients at continued risk for recurrent DVT and/or PE after completion of initial treatment lasting at least 6 months.

• Pulmonary infarct treatment is not directly mentioned in the provided drug labels.
• However, pulmonary embolism (PE) treatment is indicated for both rivaroxaban (XARELTO) 2 and apixaban 3.
• Since pulmonary infarct is a complication of pulmonary embolism, treatment of the underlying PE may be implied, but this is not explicitly stated.
• Therefore, the treatment of pulmonary infarct is not directly addressed in the provided drug labels.

From the Research

Treatment Options for Pulmonary Infarct

• The initial treatment of patients with acute pulmonary embolism has traditionally involved unfractionated heparin, but low molecular weight heparins are gradually replacing heparin due to their more predictable pharmacodynamic and pharmacokinetic properties 4.
• Low molecular weight heparins, such as enoxaparin, dalteparin, and nadroparin, are preferred over unfractionated heparin in the initial anticoagulation of pulmonary embolism due to their lower risk of bleeding 5, 6.
• Fondaparinux, a synthetic pentasaccharide, is also a promising alternative for the prevention and treatment of venous thromboembolism 7.
• Thrombolytic therapy may be useful in cases of massive pulmonary embolism, but more evaluation is needed 6.
• Outpatient treatment with low molecular weight heparin has been shown to be feasible in many patients, offering potential cost-savings and improvements in health-related quality of life 8.

Anticoagulation Therapy

• All patients with pulmonary embolism require therapeutic anticoagulation for at least three months 5.
• The decision on the duration of anticoagulation should consider both the individual risk of pulmonary embolism recurrence and the individual risk of bleeding 5.
• Non-vitamin K antagonist oral anticoagulants (NOACs), such as apixaban, edoxaban, and rivaroxaban, are effective alternatives to treatment with low molecular weight heparin, especially in patients with active cancer 5.
• The risk of recurrent pulmonary embolism after discontinuation of treatment is related to the features of the index pulmonary embolism event, and patients with a strong transient risk factor have a low risk of recurrence 5.

Monitoring and Adverse Effects

• Bleeding and heparin thrombocytopenia are the main adverse effects of anticoagulant therapy 6.
• Monitoring with an anti-factor Xa assay may be necessary in patients with severe obesity or renal insufficiency 7.
• Protamine may help to reverse bleeding related to low molecular weight heparin, although anti-factor Xa activity is not fully normalized by protamine 7.