What is the recommended duration of anticoagulation therapy for a 75-year-old man with extensive bilateral pulmonary emboli (PE), diagnosed via computed tomography (CT) pulmonary angiography, who is normotensive, without hypoxia or tachycardia, and has no evidence of right heart strain, following a recent long-haul flight from Australia to Malaysia and Singapore, with a past medical history of hypertension and robotic radical prostatectomy for prostate carcinoma?

From the Guidelines

Anticoagulation therapy should be continued for at least 3 months in a 75-year-old man with extensive bilateral pulmonary emboli following international travel, as recommended by the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism 1. The patient's presentation with extensive bilateral pulmonary emboli after travelling to Malaysia and Singapore from Australia 2 weeks prior, in the absence of hypoxia, normotensive, no tachycardia, and no evidence of right heart strain, suggests a provoked pulmonary embolism (PE) due to a major transient/reversible risk factor, namely long-distance travel.

• According to the 2019 ESC guidelines, therapeutic anticoagulation for more than 3 months is recommended for all patients with PE, and for patients with first PE/VTE secondary to a major transient/reversible risk factor, discontinuation of therapeutic oral anticoagulation is recommended after 3 months 1.
• The patient's medical history of hypertension and robotic radical prostatectomy 2 years prior for prostate carcinoma does not significantly impact the decision on anticoagulation duration, as there is no evidence of cancer-related thrombosis or ongoing risk factors for recurrence.
• After the initial 3-month period, the need for extended anticoagulation should be reassessed based on risk-benefit analysis, taking into account the patient's bleeding risk, which should be assessed using prediction models, such as those outlined in Supplementary Data Table 14 of the 2019 ESC guidelines 1.
• If extended oral anticoagulation is decided after PE in a patient without cancer, a reduced dose of the NOACs apixaban (2.5 mg b.i.d.) or rivaroxaban (10 mg o.d.) should be considered after 6 months of therapeutic anticoagulation, as recommended by the 2019 ESC guidelines 1.
• Regular monitoring for bleeding complications is essential, particularly given the patient's age, which slightly increases bleeding risk, and the patient should also be advised on preventive measures for future long-distance travel, including hydration, regular movement, and compression stockings.

From the Research

Anticoagulation Duration for Pulmonary Embolism

The duration of anticoagulation for a 75-year-old man with extensive bilateral pulmonary emboli, no hypoxia, normotensive, no tachycardia, and no evidence of right heart strain is not directly addressed in the provided studies. However, the studies provide information on the treatment of venous thromboembolism (VTE) with anticoagulants.

Treatment of Venous Thromboembolism

• The study 2 recommends consideration of the use of oral edoxaban or rivaroxaban for the treatment of VTE in patients with cancer.
• The study 3 found no significant difference in the incidence of major bleeding, recurrent deep venous thrombosis, or minor bleeding in patients with active malignancy treated with apixaban or low-molecular-weight heparin (LMWH).
• The study 4 reports on the coagulation markers in patients with VTE treated with 10 mg apixaban twice daily, but does not provide information on the duration of anticoagulation.

Anticoagulation Management

• The study 5 evaluates the use of a heparin-calibrated antifactor Xa assay for measuring the anticoagulant effect of oral direct Xa inhibitors, including apixaban.
• The study 6 compares the efficacy and safety of novel oral anticoagulants (NOACs), including apixaban, dabigatran, edoxaban, and rivaroxaban, for the initial and long-term treatment of VTE.

Considerations for Anticoagulation Duration

• The patient's history of prostate carcinoma and robotic radical prostatectomy 2 years prior, as well as his hypertension, should be considered when determining the duration of anticoagulation.
• The patient's recent travel to Malaysia and Singapore from Australia 2 weeks prior may be a contributing factor to the development of pulmonary embolism, but does not directly impact the duration of anticoagulation.
• The lack of hypoxia, normotensive, no tachycardia, and no evidence of right heart strain suggests a stable clinical condition, but the duration of anticoagulation should be determined based on individual patient factors and clinical guidelines.