Can a patient with an Internal Cardiac Defibrillator (ICD) tube in situ and streaks of hemoptysis, diagnosed with pulmonary embolism, be started on Clexane (enoxaparin)?

Anticoagulation in PE with Hemoptysis and ICD

Yes, you can start Clexane (enoxaparin) in this patient with pulmonary embolism, despite the presence of streaks of hemoptysis and an ICD (intercostal drain, not Internal Cardiac Defibrillator) in situ, as the mortality risk from untreated PE outweighs the bleeding risk from minor hemoptysis.

Risk-Benefit Analysis

The presence of streaks of hemoptysis alone is not an absolute contraindication to anticoagulation in acute PE. The 2019 ESC guidelines emphasize that anticoagulation should be initiated without delay in suspected PE while diagnostic workup is in progress 1. The critical distinction here is between:

• Minor hemoptysis (blood-streaked sputum): Not a contraindication to anticoagulation
• Massive hemoptysis (>100-200 mL/24 hours): Absolute contraindication to anticoagulation

Immediate Management Approach

Initiate anticoagulation immediately unless the patient has active major bleeding 1. For non-high-risk PE:

• Start LMWH (enoxaparin/Clexane) at 1 mg/kg subcutaneously twice daily as the preferred parenteral anticoagulant over unfractionated heparin 1
• The ESC guidelines give a Class I recommendation for initiating anticoagulation in suspected PE without hemodynamic instability while diagnostic workup continues 1

Specific Considerations for This Patient

The ICD (Intercostal Drain)

• An intercostal chest tube is not an absolute contraindication to therapeutic anticoagulation
• The tube is already in place, so the procedural bleeding risk has passed
• Monitor the drain output carefully for increasing hemorrhage

The Hemoptysis

• Streaks of hemoptysis are common in PE itself due to pulmonary infarction and are not a contraindication to treatment 1
• The hemoptysis may actually improve with anticoagulation as the PE is treated
• Withholding anticoagulation carries a significantly higher mortality risk from PE progression than the bleeding risk from minor hemoptysis

Monitoring Strategy

While on enoxaparin therapy:

• Monitor chest tube output for increasing blood volume
• Assess hemoptysis severity daily (volume, frequency, color)
• Check hemoglobin/hematocrit at baseline and serially
• Watch for signs of major bleeding: hemodynamic instability, drop in hemoglobin >2 g/dL, need for transfusion 1

Transition to Oral Anticoagulation

After at least 5 days of parenteral anticoagulation 2:

• Transition to a NOAC (apixaban, rivaroxaban, dabigatran, or edoxaban) as the preferred oral anticoagulant over warfarin 1
• The ESC guidelines give a Class I recommendation for NOACs over vitamin K antagonists in eligible PE patients 1

When to Withhold Anticoagulation

Absolute contraindications that would require withholding enoxaparin:

• Active major bleeding (>200 mL hemoptysis in 24 hours)
• Hemodynamic instability from bleeding
• Recent intracranial hemorrhage or neurosurgery
• Severe thrombocytopenia (<50,000/μL)

Critical Pitfall to Avoid

Do not delay anticoagulation while waiting for hemoptysis to completely resolve. The mortality risk from untreated PE (15-30% in untreated cases) far exceeds the risk of worsening minor hemoptysis with anticoagulation 1. The hemoptysis itself may be a manifestation of the PE and could improve with treatment.