From the Guidelines
Managing anticoagulation in a patient with bilateral pulmonary embolisms and significant bleeding risk requires careful consideration of the most recent and highest quality evidence, which suggests that initial treatment should involve low molecular weight heparin (LMWH) or fondaparinux, with a potential transition to a direct oral anticoagulant (DOAC) like apixaban or rivaroxaban, while implementing bleeding risk reduction strategies and considering temporary IVC filter placement in patients with absolute contraindications to anticoagulation, as recommended by the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1.
When managing anticoagulation in a patient with bilateral pulmonary embolisms (PEs) and significant bleeding risk, it is essential to balance the risks of thrombosis and hemorrhage. The patient's history of recent left knee arthroscopy, syncopal episode, and nausea, as well as the presence of pulmonary emboli in the bilateral segmental and subsegmental branches of the pulmonary arteries, increases the complexity of the case.
Key considerations in this case include:
- The use of LMWH or fondaparinux as initial treatment, with a potential transition to a DOAC like apixaban or rivaroxaban, as recommended by the American College of Chest Physicians evidence-based clinical practice guidelines 1.
- The implementation of bleeding risk reduction strategies, such as proton pump inhibitors for GI protection, avoiding concurrent antiplatelet agents when possible, maintaining blood pressure control, and frequent monitoring of renal function and complete blood counts.
- The consideration of temporary IVC filter placement in patients with absolute contraindications to anticoagulation, as recommended by the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1.
- The importance of reassessing the risks and benefits of anticoagulation at regular intervals, such as 3 months, to determine the optimal duration of treatment.
In the context of the patient's recent hospital course, which included a drop in hemoglobin from 10.3-7.5 while on heparin drip, the decision to hold anticoagulation and consult hematology was appropriate. The subsequent placement of an IVC filter and the recommendation to continue off anticoagulation until approximately 06/23/2025, at which point the patient is to start on prophylactic Lovenox, are also consistent with the recommended approach.
Overall, the management of anticoagulation in this patient requires careful consideration of the most recent and highest quality evidence, as well as close monitoring and regular reassessment of the risks and benefits of treatment.
From the FDA Drug Label
Lovenox doses in the clinical trials for prophylaxis of deep vein thrombosis following abdominal or hip or knee replacement surgery or in medical patients with severely restricted mobility during acute illness ranged from 40 mg subcutaneously once daily to 30 mg subcutaneously twice daily The rates of major bleeding events have been reported during clinical trials with Lovenox Bleeding complications were considered major: (1) if the hemorrhage caused a significant clinical event, or (2) if accompanied by a hemoglobin decrease ≥2 g/dL or transfusion of 2 or more units of blood products
The patient has bilateral pulmonary embolisms and a significant risk of bleeding, as evidenced by a drop in hemoglobin from 10.3 to 7.5 while on heparin drip. Anticoagulation management should be approached with caution.
- The patient was initially started on heparin drip but had to be placed on hold due to a significant drop in hemoglobin.
- The patient required a total of 3 units of PRBCs and was transferred to the ICU due to hypotension.
- Pulmonology recommended continuing off anticoagulation for now, with plans to start prophylactic Lovenox on 06/23/2025.
- The patient will need to follow up with pulmonology in approximately 3 weeks for possible increase in dose of anticoagulation. Given the patient's significant risk of bleeding, it is reasonable to delay anticoagulation until the risk of bleeding has decreased, as recommended by pulmonology 2.
From the Research
Hospital Course Summary
The patient, Regina Nicolais-Miller, was admitted to the hospital for treatment of bilateral pulmonary embolisms. She was initially started on heparin drip, but had to be taken off anticoagulation due to a significant drop in hemoglobin levels. The patient required multiple blood transfusions and was transferred to the ICU due to hypotension.
Management of Anticoagulation
- The patient's anticoagulation management was complicated by the risk of bleeding, as evidenced by the drop in hemoglobin levels while on heparin drip 3.
- The use of low-molecular-weight heparins, such as enoxaparin, has been shown to be effective in preventing recurrent venous thromboembolism, but may also increase the risk of bleeding 4, 5.
- In patients with a high risk of bleeding, mechanical prophylaxis and inferior vena cava filters may be preferred over pharmacological thromboprophylaxis 6.
- The patient was eventually started on prophylactic Lovenox, with plans to follow up with pulmonology in approximately 3 weeks to reassess the need for anticoagulation 7.
Diagnostic Findings
- The patient underwent multiple imaging studies, including CT scans and an MRI, which revealed a partially liquified hematoma in the distal medial quadriceps muscle and heme arthrosis in the knee joint.
- The patient was also found to have a hypodense liver lesion, which was deemed indeterminate.
- The patient's vaginal fistula was evaluated by Ob/Gyn, but no further intervention was needed.
Multidisciplinary Care
- The patient was seen by multiple specialists, including pulmonology, surgery, orthopedics, and urology, to manage the various complications that arose during the hospital course.
- The patient's care was coordinated to ensure that all aspects of their condition were addressed, including the pulmonary embolisms, bleeding risk, and other comorbidities.