What to do after an Embolism (EMB)?

From the Guidelines

Therapeutic anticoagulation for more than 3 months is recommended for all patients with pulmonary embolism (PE). When considering the management of patients after an embolism, it's crucial to prioritize their morbidity, mortality, and quality of life. According to the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism 1, the primary goal is to prevent recurrent venous thromboembolism (VTE) while minimizing the risk of anticoagulant-related bleeding.

Key Recommendations

• Therapeutic anticoagulation for more than 3 months is recommended for all patients with PE 1.
• For patients with a first PE/VTE secondary to a major transient/reversible risk factor, discontinuation of therapeutic oral anticoagulation is recommended after 3 months 1.
• Oral anticoagulant treatment of indefinite duration is recommended for patients presenting with recurrent VTE not related to a major transient or reversible risk factor 1.
• Extended oral anticoagulation of indefinite duration should be considered for patients with a first episode of PE and no identifiable risk factor, or those with a persistent risk factor other than antiphospholipid antibody syndrome 1.

Anticoagulation Regimen

The choice of anticoagulant and duration of treatment should be individualized based on the patient's risk factors, bleeding risk, and other clinical considerations. For patients who require extended anticoagulation, a reduced dose of non-vitamin K antagonist oral anticoagulants (NOACs) such as apixaban (2.5 mg twice daily) or rivaroxaban (10 mg once daily) may be considered after 6 months of therapeutic anticoagulation 1. Regular assessment of drug tolerance, adherence, hepatic and renal function, and bleeding risk is also recommended 1.

From the FDA Drug Label

After deep subcutaneous (intrafat) injections, tests for adequacy of dosage are best performed on samples drawn 4 to 6 hours after the injection Periodically monitor platelet counts, hematocrit, and occult blood in stool during the entire course of heparin therapy, regardless of the route of administration. The FDA drug label does not answer the question.

From the Research

Treatment After an Embolism

• The initial treatment of haemodynamically stable patients with pulmonary embolism (PE) has dramatically changed since the introduction of low molecular weight heparins (LMWHs) and direct oral anticoagulant drugs (DOACs) 2.
• Anticoagulation therapy is the standard treatment of patients with symptomatic venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, and can be based on parenteral or low-molecular-weight heparin for initial therapy and oral vitamin K antagonists or DOACs for long-term therapy 3.
• The duration of anticoagulant therapy for venous thromboembolism is a topic of ongoing debate, with some patients requiring extended duration of treatment to decrease the risk of recurrent thrombosis, while others may be at increased risk of bleeding 4.

Anticoagulation Therapy

• Anticoagulation drugs, ranging from different preparations of heparin, warfarin, and newer direct oral drugs such as rivaroxaban and dabigatran, work mainly by inhibiting important factors and enzymes in the coagulation cascade 4.
• The initial treatment of pulmonary embolism is based on anticoagulants with rapid onset of action, either parenteral (heparin/fondaparinux) or oral (direct oral anticoagulants, DOACs) 5.
• Beyond the initial 3-month period, an individual re-evaluation of the risk-to-benefit ratio of anticoagulation should be performed, based on several factors, including the type of index event, age, sex, D-dimer and residual venous obstruction 5.

Management of Pulmonary Embolism

• Pulmonary embolism management is an active area of research that is rapidly evolving, and clinical consensus statements have been published that offer a guide to PE management 6.
• The PE response team (PERT) concept offers a rapid and multidisciplinary approach to managing pulmonary embolism, including diagnosis, risk stratification, therapeutic alternatives, and follow-up care 6.
• Anticoagulation is essential unless contraindicated, and thrombolysis, surgical embolectomy, and catheter-directed approaches are also available for the management of pulmonary embolism 6.