What is the best treatment approach for a suspected pulmonary embolism (PE) in a 97-year-old man?

From the Guidelines

The best treatment approach for a suspected pulmonary embolism (PE) in a 97-year-old man is to initiate anticoagulation therapy as soon as possible, while the diagnostic workup is ongoing, unless the patient is bleeding or has absolute contraindications, as recommended by the 2019 ESC guidelines 1.

Key Considerations

• Initial management should include prompt diagnostic confirmation with CT pulmonary angiography or ventilation-perfusion scan if possible.
• Anticoagulation with low molecular weight heparin (such as enoxaparin 1 mg/kg twice daily) or direct oral anticoagulants (DOACs) like apixaban (5 mg twice daily) or rivaroxaban (15 mg twice daily for 21 days, then 20 mg daily) is recommended, with a preference for NOACs over the traditional LMWH-VKA regimen unless contraindicated 1.
• In very elderly patients, dose adjustments may be necessary based on renal function, weight, and bleeding risk.
• Treatment duration is typically 3-6 months, but this should be individualized, taking into account the patient's comorbidities, functional status, medication interactions, and preferences.
• Thrombolytic therapy is generally avoided in this age group unless the patient has massive PE with hemodynamic instability, as recommended by the 2020 ESC guidelines 1.

Monitoring and Follow-up

• Close monitoring for bleeding complications is essential, with regular assessment of complete blood count, renal function, and clinical signs of bleeding.
• The treatment plan should be developed with consideration of the patient's comorbidities, functional status, medication interactions, and preferences, ideally involving a multidisciplinary approach with geriatric consultation.
• Regular follow-up examinations are recommended to weigh the benefits vs. risks of continuing treatment and to decide on the extension and dose of anticoagulant therapy, also considering the patient's preference 1.

From the FDA Drug Label

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

The recommended dose of apixaban tablets is 10 mg taken orally twice daily for the first 7 days of therapy. After 7 days, the recommended dose is 5 mg taken orally twice daily.

The recommended dose of apixaban tablets is 2.5 mg twice daily in patients with at least two of the following characteristics: • age greater than or equal to 80 years • body weight less than or equal to 60 kg • serum creatinine greater than or equal to 1.5 mg/dL

For a 97-year-old man with a suspected pulmonary embolism (PE), the best treatment approach would be to administer apixaban at a dose of 2.5 mg twice daily, considering his age as a characteristic that warrants a reduced dose 2.

• Key considerations:
  • Age: The patient is 97 years old, which is a characteristic that warrants a reduced dose of apixaban.
  • Dose adjustment: The recommended dose for patients with at least two of the specified characteristics, including age greater than or equal to 80 years, is 2.5 mg twice daily.
  • Treatment duration: The treatment duration for PE with apixaban is not explicitly stated in the provided text, but the standard treatment protocol typically involves an initial higher dose (10 mg twice daily) for the first 7 days, followed by a reduced dose (5 mg twice daily) for the remainder of the treatment period. However, for this patient, the reduced dose of 2.5 mg twice daily is recommended due to his age.

It is essential to monitor the patient closely for signs of bleeding or other adverse effects and adjust the treatment plan as necessary 2.

From the Research

Treatment Approach for Suspected Pulmonary Embolism (PE) in a 97-Year-Old Man

The treatment approach for a suspected pulmonary embolism (PE) in a 97-year-old man should be based on the patient's clinical probability of PE, medical history, and risk factors.

• The initial treatment for most patients with deep venous thrombosis or pulmonary embolism is usually a low-molecular-weight heparin (LMWH) 3.
• Unfractionated heparin is generally recommended for patients with renal failure 3.
• For patients with a high probability of PE, chest imaging is necessary, and D-dimer testing is not required 4.
• Direct oral anticoagulants (DOACs) such as apixaban, edoxaban, rivaroxaban, or dabigatran are noninferior to heparin combined with a vitamin K antagonist for treating PE and have a lower rate of bleeding 4.
• Systemic thrombolysis is recommended for patients with PE and systolic blood pressure lower than 90 mm Hg 4.

Anticoagulation Therapy

• Anticoagulation is performed with unfractionated heparin (UFH) in hemodynamically unstable patients and with low molecular weight heparins (LMWH) or fondaparinux in normotensive patients 5.
• LMWH and fondaparinux are preferred over UFH in the initial anticoagulation of PE since they are associated with a lower risk of bleeding 5.
• All patients with PE require therapeutic anticoagulation for at least three months 5.
• The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 5.

Specific Considerations for a 97-Year-Old Man

• The patient's age and medical history should be taken into account when selecting an anticoagulant therapy 6.
• The risk of bleeding and the risk of recurrent PE should be carefully evaluated when deciding on the duration of anticoagulation 5.
• Extended oral anticoagulation of indefinite duration should be considered for patients with intermediate risk of recurrence 5.