What are the indications for treating pulmonary embolism (PE) with heparin versus Eliquis (apixaban) and for hospital admission versus outpatient management?

Treatment Selection: Heparin vs Eliquis for Pulmonary Embolism

When to Use Heparin vs Eliquis (Apixaban)

For low-risk, hemodynamically stable PE patients, apixaban is preferred as a single-drug regimen that allows outpatient treatment, while unfractionated heparin is mandatory for high-risk PE with shock or hypotension. 1

Use Unfractionated Heparin When:

• High-risk PE with shock or hypotension - IV unfractionated heparin must be initiated immediately as LMWH and DOACs have not been tested in hemodynamically unstable patients 1
• Severe renal dysfunction (creatinine clearance <30 mL/min or eGFR <30 mL/min) - apixaban and other DOACs are contraindicated 1, 2
• High bleeding risk - unfractionated heparin allows rapid reversal and precise titration via aPTT monitoring (target 1.5-2.5 times control) 1
• Planned thrombolysis or embolectomy - high-risk patients requiring escalation of therapy need the flexibility of IV heparin 1
• Recent major bleeding or surgery - when anticoagulation must be carefully monitored and potentially reversed quickly 1
• Heparin-induced thrombocytopenia within the past year (if no alternative exists) 1

Use Apixaban (Eliquis) When:

• Non-high-risk PE (hemodynamically stable without shock) - apixaban 10 mg twice daily for 7 days, then 5 mg twice daily is recommended 1, 2
• Outpatient management is planned - single-drug regimen eliminates need for parenteral bridging therapy 1
• Normal or mild-moderate renal function (creatinine clearance ≥30 mL/min) 2
• Lower bleeding risk preferred - apixaban shows 27-39% reduction in major bleeding vs warfarin with heparin bridge 3
• Simplified dosing desired - no monitoring required, fixed dosing based on indication 2

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Hospital Admission vs Outpatient Management

Low-risk PE patients identified by PESI/sPESI scoring can be safely managed as outpatients with mortality rates of 1.7% at 30 days, comparable to inpatient care. 1

Admit to Hospital When:

Hemodynamic instability:

• Systolic blood pressure <90 mmHg or drop ≥40 mmHg 1
• Shock or persistent hypotension requiring vasopressors 1
• Heart rate >110 bpm (Hestia criteria) 1

High-risk clinical features:

• PESI class III-V or sPESI score ≥1 1
• Right ventricular dysfunction on imaging with elevated cardiac biomarkers (troponin, BNP/NT-proBNP) 1
• Oxygen saturation <90% on room air 1
• Active bleeding or very high bleeding risk 1

Medical complexity:

• Severe renal failure (eGFR <30 mL/min) or severe liver disease 1
• Severe pain requiring parenteral opiates 1
• Other acute medical comorbidities requiring hospitalization 1
• Recent GI bleeding or surgery within 3 months 1
• Platelet count <75,000/mm³ 1
• Therapeutic anticoagulation (INR ≥2.0) at diagnosis 1

Social factors:

• Inability to return home or inadequate home care 1
• Lack of telephone communication 1
• Concerns about medication compliance 1
• Pregnancy or postpartum period (requires consultant review) 1

Discharge Home (Outpatient) When:

Low-risk criteria met:

• PESI class I-II or sPESI score of 0 1
• Hemodynamically stable (normal blood pressure, heart rate <110 bpm) 1
• Oxygen saturation adequate on room air 1
• No active bleeding or high bleeding risk 1

Clinical stability:

• No severe pain requiring parenteral analgesia 1
• No other medical conditions requiring admission 1
• Adequate renal function (eGFR ≥30 mL/min for apixaban) 1, 2

Logistical requirements:

• Ability to return for follow-up within 24 hours if needed 1
• Adequate home support and telephone access 1
• Patient understanding and ability to comply with anticoagulation 1

Imaging considerations:

• RV dilatation alone on CT does not mandate admission if biomarkers are normal and patient meets low-risk criteria 1
• If RV dysfunction present, normal biomarkers can support outpatient management 1

Early Discharge Option:

Patients initially admitted with intermediate-risk PE (PESI class III) can be considered for early discharge (<72 hours) when they meet low-risk criteria (PESI class I-II or sPESI 0) after initial stabilization. 1 Meta-analysis shows early discharge patients have comparable outcomes: 1.1% recurrent VTE, 0.78% major bleeding, and 2.3% mortality at 30 days 1.

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Key Clinical Pitfalls:

• Never use apixaban or other DOACs in high-risk PE with hemodynamic instability - these patients were excluded from all DOAC trials 1
• Do not rely solely on RV dysfunction for admission decisions - combine with biomarkers and clinical risk scores 1
• Avoid discharging patients with severe renal dysfunction on apixaban - creatinine clearance <30 mL/min is a contraindication 2
• Ensure robust same-day or next-day follow-up systems before implementing outpatient PE pathways 1
• Pregnant patients require consultant review and should not use DOACs or warfarin; LMWH is the anticoagulant of choice 1