What is the next step in management for a patient with deep vein thrombosis (DVT) on Eliquis (apixaban) presenting with shortness of breath?

Management of DVT Patient on Eliquis with Shortness of Breath

A patient with DVT on Eliquis who develops shortness of breath should immediately undergo CT pulmonary angiography (CTPA) to rule out pulmonary embolism, as this represents the most appropriate next diagnostic step.

Initial Assessment

• Shortness of breath in a patient with DVT already on anticoagulation raises high suspicion for pulmonary embolism (PE), which requires immediate evaluation 1
• The combination of DVT and new-onset dyspnea significantly increases the clinical probability of PE, warranting immediate diagnostic imaging 1
• Initial assessment should include vital signs (particularly respiratory rate >20/min), oxygen saturation, and evaluation for signs of hemodynamic instability 1

Diagnostic Approach

First-Line Imaging

• CT pulmonary angiography (CTPA) is the first-line imaging modality for suspected PE in a patient with DVT on anticoagulation 1
• CTPA is rated as "usually appropriate" (highest rating) for evaluation of suspected PE in patients with DVT 1
• Chest radiography should be performed prior to CTPA to rule out other causes of dyspnea but should not delay definitive imaging 1

Alternative Imaging Options

• If CTPA is contraindicated (severe renal impairment, contrast allergy):
  • V/Q scan can be considered, though it is less useful in patients with abnormal chest radiographs or underlying lung disease 1
  • MR angiography of the chest may be appropriate in select cases (rated 3/9) 1

Management Based on Findings

If PE is Confirmed

• Continue apixaban therapy at the current dose of 5mg twice daily if the patient has been on treatment for more than 7 days 2
• If PE is confirmed and the patient is hemodynamically unstable, consider thrombolytic therapy (50mg alteplase IV) 1, 3
• Assess for treatment failure, which may require consideration of:
  • Medication adherence issues with apixaban 4
  • Need for inferior vena cava filter if recurrent PE despite therapeutic anticoagulation 3

If PE is Excluded

• Investigate alternative causes of dyspnea, including cardiac or pulmonary conditions 1
• Continue apixaban as prescribed for the original DVT 2

Anticoagulation Considerations

• Verify current apixaban dosing is appropriate:
  • Initial treatment phase: 10mg twice daily for first 7 days
  • Maintenance phase: 5mg twice daily 2
• Do not interrupt anticoagulation while awaiting diagnostic confirmation unless there are absolute contraindications to anticoagulation 3
• For recurrent thromboembolism while on therapeutic anticoagulation, indefinite oral anticoagulant treatment is strongly recommended 4, 3

Important Pitfalls to Avoid

• Do not delay imaging in a patient with DVT and new shortness of breath, as PE is a potentially fatal condition requiring prompt diagnosis 1
• Do not discontinue anticoagulation while awaiting diagnostic confirmation unless there are absolute contraindications 3
• Do not rely solely on D-dimer testing in this clinical scenario, as it has limited value in patients already diagnosed with DVT and on anticoagulation 1
• Avoid assuming that current anticoagulation therapy precludes the possibility of PE, as breakthrough embolic events can occur due to medication non-adherence or treatment failure 4