What is the recommended treatment for Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE) with thrombus in the heart?

From the Guidelines

The recommended treatment for Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE) with thrombus in the heart typically involves immediate anticoagulation therapy, often with a parenteral anticoagulant followed by oral anticoagulants, as suggested by the American Society of Hematology 2020 guidelines 1. The initial treatment usually begins with low molecular weight heparin (LMWH) such as enoxaparin (1 mg/kg twice daily or 1.5 mg/kg once daily), unfractionated heparin (UFH), or fondaparinux (5-10 mg daily based on weight). This is typically overlapped with an oral anticoagulant like warfarin (target INR 2-3) or a direct oral anticoagulant (DOAC) such as rivaroxaban (15 mg twice daily for 21 days, then 20 mg once daily), apixaban (10 mg twice daily for 7 days, then 5 mg twice daily), or edoxaban (60 mg once daily after 5-10 days of parenteral anticoagulation). Some key points to consider in the treatment of DVT and PE include:

• The use of thrombolytic therapy for patients with PE and hemodynamic compromise, as recommended by the European Society of Cardiology 1
• The preference for home treatment over hospital-based treatment for uncomplicated DVT and PE at low risk for complications, as suggested by the American Society of Hematology 2020 guidelines 1
• The use of indefinite anticoagulation for patients with recurrent unprovoked VTE, as recommended by the American Society of Hematology 2020 guidelines 1
• The choice of long-term anticoagulant therapy, with options including dabigatran, rivaroxaban, apixaban, or edoxaban over vitamin K antagonist (VKA) therapy, as suggested by the Chest guideline and expert panel report 1 The presence of thrombus in the heart may warrant more aggressive treatment, potentially including thrombolytic therapy with agents like alteplase (100 mg over 2 hours) in hemodynamically unstable patients. Treatment duration is typically 3-6 months, but may be extended based on risk factors. Patients should be monitored for bleeding complications and may require hospitalization initially. This approach is effective because anticoagulants prevent further clot formation while allowing the body's natural fibrinolytic system to gradually dissolve existing clots, reducing the risk of clot propagation and embolization that could lead to fatal outcomes.

From the FDA Drug Label

For patients with a first episode of DVT or PE secondary to a transient (reversible) risk factor, treatment with warfarin for 3 months is recommended For patients with a first episode of idiopathic DVT or PE, warfarin is recommended for at least 6 to 12 months. The dose of warfarin should be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations. In the EINSTEIN DVT and EINSTEIN PE studies, XARELTO was demonstrated to be non-inferior to enoxaparin/VKA for the primary composite endpoint of time to first occurrence of recurrent DVT or non-fatal or fatal PE

The recommended treatment for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) with thrombus in the heart is:

• Warfarin: for 3 months for patients with a first episode of DVT or PE secondary to a transient risk factor, and for at least 6 to 12 months for patients with a first episode of idiopathic DVT or PE.
• Rivaroxaban (XARELTO): as an alternative to warfarin, with a dose of 15 mg twice daily for the first three weeks, followed by 20 mg once daily. Key points:
• The dose of warfarin should be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations.
• Rivaroxaban was demonstrated to be non-inferior to enoxaparin/VKA for the primary composite endpoint of time to first occurrence of recurrent DVT or non-fatal or fatal PE 2.
• The treatment duration should be individualized based on the patient's risk factors and response to treatment 3.

From the Research

Treatment of DVT, Pulmonary Embolism with Thrombus in the Heart

The treatment of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE) with thrombus in the heart involves the use of anticoagulants to prevent the progression of the disease and reduce the risk of complications. The following are some of the key points to consider:

• The traditional treatment of venous thromboembolism (VTE) with heparin and warfarin has numerous limitations, and new oral anticoagulants such as apixaban, rivaroxaban, and dabigatran have emerged as promising alternatives 4, 5, 6.
• Apixaban is an oral factor Xa inhibitor with a rapid onset of action and predictable pharmacokinetics, making it a simple and effective treatment option for VTE 4, 7.
• The use of direct oral anticoagulants (DOACs) such as apixaban and rivaroxaban has been shown to be at least as effective and safer than vitamin K antagonists (VKAs) such as warfarin for the treatment of left ventricular thrombus (LVT) 8.
• DOACs are the preferred treatment for DVT because they are at least as effective, safer, and more convenient than warfarin, but may require dose reduction or avoidance in patients with renal dysfunction, and should be avoided in pregnancy 6.
• The choice of anticoagulant depends on various factors, including the patient's medical history, renal function, and preference, and should be individualized to ensure the best possible outcome 5, 7, 6.

Anticoagulation Options

Some of the anticoagulation options for the treatment of DVT, PE with thrombus in the heart include:

• Apixaban: an oral factor Xa inhibitor with a rapid onset of action and predictable pharmacokinetics 4, 7.
• Rivaroxaban: an oral factor Xa inhibitor with a rapid onset of action and predictable pharmacokinetics 5, 8, 6.
• Dabigatran: an oral direct thrombin inhibitor with a rapid onset of action and predictable pharmacokinetics 6.
• Edoxaban: an oral factor Xa inhibitor with a rapid onset of action and predictable pharmacokinetics 6.
• Warfarin: a vitamin K antagonist with a slower onset of action and less predictable pharmacokinetics, requiring regular laboratory monitoring 4, 5, 6.

Special Considerations

Some special considerations for the treatment of DVT, PE with thrombus in the heart include:

• Patients with cancer: may be treated with edoxaban or rivaroxaban, but the risk of gastrointestinal bleeding is higher with DOACs than with low molecular weight heparin (LMWH) 6.
• Patients with renal dysfunction: may require dose reduction or avoidance of DOACs 6.
• Patients with pregnancy: should avoid the use of DOACs 6.
• Patients with a history of heparin-induced thrombocytopenia or identified forms of thrombophilia: may require special consideration and alternative anticoagulation options 7.