What are the management options for an 83-year-old male with a massive pulmonary embolism post thrombolysis on IV heparin?

From the Guidelines

For an 83-year-old man with a massive pulmonary embolism (PE) who has received thrombolysis and is currently on IV heparin, the recommended next step is to continue anticoagulation therapy with careful monitoring, preferably transitioning to a direct oral anticoagulant (DOAC) once stabilized, as suggested by the 2019 ESC guidelines 1.

Key Considerations

• The patient should remain on IV unfractionated heparin with a target aPTT of 1.5-2.5 times the control value for at least 24-48 hours post-thrombolysis, as per standard practice.
• Once stabilized, transition to oral anticoagulation is appropriate, with a preference for DOACs such as apixaban, rivaroxaban, or edoxaban, due to their favorable risk-benefit profile compared to traditional anticoagulants 1.
• If DOACs are contraindicated, warfarin with a target INR 2-3, overlapping with heparin for at least 5 days until therapeutic INR is achieved for 24 hours, is an alternative.

Anticoagulation Management

• Anticoagulation should continue for at least 3-6 months, with consideration for extended therapy based on risk-benefit assessment, taking into account the patient's age, comorbidities, and the risk of recurrent VTE 1.
• Close monitoring for bleeding complications is essential, particularly in this elderly patient post-thrombolysis, due to the increased risk of bleeding associated with anticoagulation therapy.

Additional Care

• Oxygen supplementation should be provided as needed, and the patient should be monitored in an intensive care setting initially, to ensure close surveillance for any potential complications.
• Regular follow-up examinations are crucial to assess for possible signs of VTE recurrence, cancer, or bleeding complications of anticoagulation, and to evaluate the patient's functional status and potential need for further intervention 1.

From the FDA Drug Label

When initiating treatment with Heparin Sodium Injection by continuous intravenous infusion, determine the coagulation status (aPTT, INR, platelet count) at baseline and continue to follow aPTT approximately every 4 hours and then at appropriate intervals thereafter The dosing recommendations in Table 1 are based on clinical experience be adjusted for the individual patient according to the results of suitable laboratory tests, the following dosage schedules may be used as guidelines: Table 1: Recommended Adult Full-Dose Heparin Regimens for Therapeutic Anticoagulant Effect *Based on 68 kg patient METHOD OF ADMINISTRATION FREQUENCY RECOMMENDED DOSE Continuous Intravenous Infusion Initial Dose 5,000 units by intravenous injection Continuous 20,000 to 40,000 units/24 hours in 1,000 mL of 0.9% Sodium Chloride Injection, USP (or in any compatible solution) for infusion

The patient is an 83-year-old male with a massive pulmonary embolism (PE) post-thrombolysis and is on IV heparin.

• The indication for heparin in this case is for the treatment of pulmonary embolism.
• The dosage of heparin for this patient is not explicitly stated in the provided text, but according to the label, the recommended dose for continuous intravenous infusion is an initial dose of 5,000 units by intravenous injection, followed by a continuous infusion of 20,000 to 40,000 units/24 hours.
• It is essential to monitor the patient's coagulation status, including aPTT, INR, and platelet count, at baseline and at appropriate intervals thereafter to adjust the heparin dose as needed 2, 2, 2.

From the Research

Patient Profile

• The patient is an 83-year-old male with no significant previous medical history
• He has a massive pulmonary embolism (PE) post thrombolysis and is on IV heparin

Heparin Therapy

• According to 3, high-dose heparin therapy is indicated for acute deep-vein thrombosis and pulmonary embolism
• The recommended heparin dosage is a bolus dose of 70-100 units/kg followed by an infusion of 15-25 units/kg/hr
• The goal of heparin therapy is to elevate the activated partial thromboplastin time (aPTT) to 1.5 to 2.0 times the control value

Anticoagulation Management

• A study by 4 evaluated the anticoagulation management in patients receiving catheter-directed thrombolysis with ultrasound-assisted thrombolysis (USAT) for the treatment of PE
• The study found that a therapeutic aPTT value was achieved in 54.2% of patients prior to USAT and 59.3% during tissue-plasminogen activator (tPA) infusion
• Heparin requirements were reduced from 15.1 ± 4.1 to 12.8 ± 4.2 U/kg/h for patients who achieved a therapeutic aPTT both prior to and during tPA infusion

Recurrence and Bleeding Risk

• A study by 5 found that increasing proportions of time on heparin with an aPTT ≥ 0.2 anti-X(a) U/mL and on warfarin with an INR ≥ 2.0 were associated with significant reductions in venous thromboembolism (VTE) recurrence
• The study also found that the hazard of active cancer was significantly increased
• A study by 6 compared the incidence of bleeding and thrombosis between adult venoarterial (VA) extracorporeal membrane oxygenation (ECMO) patients managed with an activated clotting time (ACT)-guided heparin anticoagulation protocol and activated partial thromboplastin time (aPTT) protocol, and found no difference in the incidence of bleeding or thrombosis between the two groups

Monitoring of Heparin Therapy

• A study by 7 compared a point-of-care (POCT) version of the aPTT to laboratory-based aPTT and measurements of anti-Xa activity in terms of correlation, agreement, and turnaround time (TAT)
• The study found that the overall correlation between POCT-APTT and laboratory APTT was strongly positive, and between POCT-APTT and anti-Xa activity was weakly positive
• The study also found that the POCT delivered results in less than 5 min, while the median TATs for lab-APTT and anti-Xa were 50.9 min and 66.3 min, respectively