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

From the Guidelines

The treatment of pulmonary infarction should focus on addressing the underlying cause, managing symptoms, and preventing complications, with anticoagulation therapy being essential, typically starting with low molecular weight heparin or unfractionated heparin, then transitioning to oral anticoagulants like warfarin or direct oral anticoagulants for at least 3-6 months, as recommended by the 2019 ESC guidelines 1.

Key Recommendations

• Initial management includes supplemental oxygen to maintain oxygen saturation above 92%
• Pain control with NSAIDs or opioids like morphine 2-4mg IV as needed
• Anticoagulation therapy with low molecular weight heparin (enoxaparin 1mg/kg twice daily) or unfractionated heparin (80 units/kg bolus followed by 18 units/kg/hour)
• Transitioning to oral anticoagulants like warfarin (target INR 2-3) or direct oral anticoagulants (apixaban 10mg twice daily for 7 days, then 5mg twice daily) for at least 3-6 months

Thrombolytic Therapy

• Thrombolytic therapy with alteplase (100mg IV over 2 hours) may be considered for massive PE with hemodynamic instability, as recommended by the 2019 ESC guidelines 1
• The use of thrombolytic therapy should be weighed against the risk of bleeding, especially in patients with predisposing conditions or comorbidities, as noted in the 2008 ESC guidelines 1

Supportive Care

• Adequate hydration
• Bronchodilators for bronchospasm
• Antibiotics only if secondary infection develops

Prevention of Recurrence

• Anticoagulation therapy should be continued for at least 3-6 months to prevent recurrence of pulmonary embolism, as recommended by the 2019 ESC guidelines 1

From the FDA Drug Label

1.4 Treatment of Pulmonary Embolism Apixaban tablets are indicated for the treatment of PE.

1. 3 Treatment of Pulmonary Embolism XARELTO is indicated for the treatment of pulmonary embolism (PE).

Pulmonary Infarct Treatment:

• The treatment for pulmonary embolism (PE) includes anticoagulation therapy.
• Apixaban 2 and rivaroxaban 3 are indicated for the treatment of PE.
• These medications can help reduce the risk of recurrent PE and other thrombotic events.
• However, the term "pulmonary infarct" is not explicitly mentioned in the provided drug labels, but it is often associated with pulmonary embolism.
• Therefore, treatment with anticoagulants like apixaban or rivaroxaban may be considered, but the specific treatment for pulmonary infarct should be guided by clinical judgment and individual patient needs.

From the Research

Treatment Options for Pulmonary Infarct

• Anticoagulants such as warfarin, unfractionated heparin (UFH), and low-molecular-weight heparins have been used for treatment of pulmonary embolism 4
• Low molecular weight heparins are gradually replacing heparin for the initial treatment of most patients diagnosed with acute pulmonary embolism, except in very obese patients or patients with renal failure 5
• New anticoagulants, such as ximelagatran, an oral direct thrombin inhibitor, or fondaparinux and idraparinux, selective factor X(a) inhibitors with an almost complete bioavailability after subcutaneous injection are promising alternatives 5

Anticoagulation Therapy

• Anticoagulation is performed with unfractionated heparin (UFH) in hemodynamically unstable patients and with low molecular weight heparins (LWMH) or fondaparinux in normotensive patients 6
• All patients with pulmonary embolism require therapeutic anticoagulation for at least three months 6
• The current 2019 guidelines of the European Society of Cardiology (ESC) recommend that all eligible patients should be treated with a non-vitamin K antagonist oral anticoagulant (NOAC) in preference to a vitamin K antagonist (VKA) 6

Duration of Anticoagulation

• The decision on the duration of anticoagulation should consider both, the individual risk of pulmonary embolism recurrence and the individual risk of bleeding 6
• Patients with a strong transient risk factor have a low risk of recurrence and anticoagulation can be discontinued after three months, while patients with strong persistent risk factor (such as active cancer) have a high risk of recurrence and thus should receive anticoagulant treatment of indefinite duration 6

Enoxaparin Monotherapy

• Enoxaparin monotherapy without oral anticoagulation is a feasible treatment option for acute symptomatic pulmonary embolism 7
• Extended 3-month treatment with enoxaparin as monotherapy for symptomatic, acute pulmonary embolism is feasible and warrants further study in a large clinical trial 7