What is the recommended duration of anticoagulation for a person with a significant pulmonary embolism?

From the Guidelines

The recommended duration of anticoagulation for a person with a significant pulmonary embolism is at least 3 months, with extended anticoagulation considered beyond 3 months based on individual risk factors and bleeding risks. According to the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism 1, therapeutic anticoagulation for more than 3 months is recommended for all patients with pulmonary embolism (PE). The guidelines suggest that for patients with a first PE secondary to a major transient or reversible risk factor, discontinuation of therapeutic oral anticoagulation is recommended after 3 months 1. However, for patients with unprovoked PE or ongoing risk factors, extended anticoagulation should be considered after weighing bleeding risks against recurrence risks.

Some key points to consider in determining the duration of anticoagulation include:

• The presence of transient or reversible risk factors, such as surgery or hospitalization, which may allow for shorter durations of anticoagulation 1
• The presence of ongoing risk factors, such as cancer, which may require extended anticoagulation 1
• The patient's bleeding risk, which should be assessed and taken into account when determining the duration of anticoagulation 1
• The use of direct oral anticoagulants (DOACs) or low-molecular-weight heparin (LMWH) as alternatives to vitamin K antagonists (VKAs) for anticoagulation 1

In terms of specific anticoagulation regimens, options include:

• Low-molecular-weight heparin (LMWH) such as enoxaparin 1 mg/kg twice daily or fondaparinux 5-10 mg daily based on weight
• Direct oral anticoagulants (DOACs) such as apixaban 5 mg twice daily, rivaroxaban 15 mg twice daily for 21 days then 20 mg once daily, dabigatran 150 mg twice daily after parenteral lead-in, or edoxaban 60 mg once daily after parenteral lead-in
• Vitamin K antagonists (VKAs) such as warfarin, dose adjusted to maintain INR 2-3

Ultimately, the decision on the duration of anticoagulation should be individualized based on the patient's specific risk factors and clinical circumstances, with consideration of the potential benefits and risks of extended anticoagulation 1.

From the Research

Duration of Anticoagulation for Pulmonary Embolism

The recommended duration of anticoagulation for a person with a significant pulmonary embolism varies depending on several factors, including the individual's risk of recurrence and risk of bleeding.

• All patients with pulmonary embolism require therapeutic anticoagulation for at least three months 2, 3, 4.
• The decision on the duration of anticoagulation should consider both the individual risk of pulmonary embolism recurrence and the individual risk of bleeding 2, 4.
• Patients with a strong transient risk factor have a low risk of recurrence, and anticoagulation can be discontinued after three months 2, 4.
• Patients with strong persistent risk factors, such as active cancer, have a high risk of recurrence and should receive anticoagulant treatment of indefinite duration 2.
• Extended oral anticoagulation of indefinite duration should be considered for all patients with an intermediate risk of recurrence, given the favorable safety profile of non-vitamin K antagonist oral anticoagulants (NOACs) 2.

Special Considerations

• In patients with cancer, apixaban, edoxaban, and rivaroxaban are effective alternatives to treatment with low molecular weight heparin (LMWH) 2.
• The choice of anticoagulant agent should be based on the individual patient's characteristics, including their risk of bleeding and recurrence, as well as their preferences and values 3, 5.
• Direct oral anticoagulants (DOACs) have been shown to have a favorable safety profile compared to traditional anticoagulants, with a lower risk of bleeding 6.

Anticoagulation Management

• The primary goal of anticoagulation management in patients with pulmonary embolism is to prevent recurrences, which can be fatal 3, 5.
• Anticoagulation management should be individualized, taking into account the patient's risk factors, medical history, and preferences 3, 5.
• Regular monitoring and follow-up are essential to ensure that the patient is receiving the most effective and safe anticoagulation therapy 3, 5.