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

From the Guidelines

Treatment of pulmonary infarction should focus on addressing the underlying cause, managing symptoms, and preventing complications, with anticoagulation therapy being the primary approach, as recommended by the 2019 ESC guidelines 1. The primary approach involves anticoagulation therapy with heparin (unfractionated heparin at 80 units/kg bolus followed by 18 units/kg/hour infusion) or low molecular weight heparin (enoxaparin 1 mg/kg twice daily), transitioning to oral anticoagulants like warfarin (target INR 2-3) or direct oral anticoagulants (apixaban 5mg twice daily, rivaroxaban 15-20mg daily) for at least 3-6 months.

• Supplemental oxygen should be provided to maintain oxygen saturation above 92% 1.
• Pain management with NSAIDs or opioid analgesics may be necessary.
• If the infarction resulted from pulmonary embolism and the patient is hemodynamically unstable, thrombolytic therapy with alteplase (100mg over 2 hours) might be considered, as recommended by the 2019 ESC guidelines 1.
• Supportive care includes adequate hydration, early mobilization, and respiratory therapy.
• For patients with significant pleural effusion causing respiratory distress, thoracentesis may be required. The treatment approach targets the thrombotic process that caused the infarction, reduces inflammation, manages pain, and supports respiratory function while the lung tissue heals.
• Close monitoring for complications such as infection, pleural effusion, or hemoptysis is essential during recovery, as emphasized by the American College of Chest Physicians evidence-based clinical practice 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, are as effective as unfractionated heparin in the treatment of patients with acute pulmonary thromboembolism, with a similar risk of bleeding 5.
• The use of low molecular weight heparin in the inpatient and outpatient settings is recommended for the treatment of pulmonary embolism, as it offers more predictable pharmacokinetics and anticoagulant effects 6.
• Anticoagulation is performed with unfractionated heparin in hemodynamically unstable patients and with low molecular weight heparins or fondaparinux in normotensive patients 7.
• All patients with pulmonary embolism require therapeutic anticoagulation for at least three months, and the decision on the duration of anticoagulation should consider both the individual risk of pulmonary embolism recurrence and the individual risk of bleeding 7.

Anticoagulant Therapy

• Low molecular weight heparins have the advantage of fixed-dose administration, once or twice daily, by subcutaneous injection, and all available low molecular weight heparins seem to have similar efficacy 8.
• Fondaparinux and rivaroxaban do not appear to have a more favorable harm-benefit balance than low molecular weight heparin followed by an adjusted-dose vitamin K antagonist 8.
• Non-vitamin K antagonist oral anticoagulants, such as apixaban, edoxaban, and rivaroxaban, are effective alternatives to treatment with low molecular weight heparin in patients with active cancer 7.
• The current guidelines recommend that all eligible patients should be treated with a non-vitamin K antagonist oral anticoagulant in preference to a vitamin K antagonist 7.

Thrombolytic Therapy

• Thrombolytic agents may be useful in case of massive pulmonary embolism, but more evaluation is needed 8.
• Adding a thrombolytic drug to initial anticoagulant therapy did not reduce mortality or recurrences after pulmonary embolism, whereas it increased the incidence of bleeding 8.
• Thrombolysis is recommended for massive pulmonary embolism and, in some guidelines, for iliofemoral venous thrombosis 8.