From the FDA Drug Label
1 INDICATIONS AND USAGE Heparin Sodium Injection is indicated for:
• Prophylaxis and treatment of venous thrombosis and pulmonary embolism; The FDA drug label does not answer the question.
From the Research
For a saddle pulmonary embolism (PE) not requiring oxygen, systemic anticoagulation with heparin is generally preferred over thrombectomy as first-line treatment. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of clinical presentation and hemodynamic status over the anatomical location of the clot 1. A heparin drip (continuous intravenous infusion) should be initiated with a bolus of 80 units/kg followed by an infusion of 18 units/kg/hour, with dose adjustments to maintain aPTT at 1.5-2.5 times normal. The rationale behind this approach is that hemodynamic stability (not requiring oxygen) suggests the patient can tolerate the clot while anticoagulation prevents further clot formation and allows natural fibrinolytic processes to work.
Some key points to consider in the management of saddle PE include:
- Thrombectomy, whether catheter-directed or surgical, is typically reserved for patients with hemodynamic instability, right ventricular dysfunction, or those who have contraindications to anticoagulation or have failed anticoagulation therapy.
- Close monitoring is essential, with consideration for escalation to thrombectomy if the patient develops hypoxemia, hemodynamic compromise, or right heart strain.
- After initial stabilization with heparin, transition to oral anticoagulation (typically a direct oral anticoagulant or warfarin) would follow for at least 3-6 months, as supported by studies comparing the efficacy and safety of different anticoagulants in the treatment of PE 2, 3, 1.
- The choice between different oral anticoagulants should be based on individual patient factors, including the risk of bleeding and the presence of any contraindications to specific medications.
It's worth noting that while older studies may suggest different approaches to the management of saddle PE, the most recent and highest quality evidence supports the use of systemic anticoagulation with heparin as first-line treatment for hemodynamically stable patients 4, 5.