In a patient with confirmed pulmonary embolism on therapeutic apixaban (Eliquis) who now has an evolving pulmonary infarction, what additional treatments are indicated?

Management of Pulmonary Embolism with Evolving Infarction on Apixaban

Continue therapeutic apixaban and focus on supportive care with close monitoring for hemodynamic deterioration, as pulmonary infarction represents a localized complication that does not require additional anticoagulation or thrombolysis in hemodynamically stable patients. 1

Immediate Assessment Required

Determine hemodynamic stability first, as this dictates the entire management pathway and mortality risk 1:

• Check for signs of high-risk PE: sustained hypotension (systolic BP <90 mmHg), persistent profound bradycardia, pulselessness, or signs of impending collapse 2, 3
• Assess for right ventricular dysfunction: perform bedside echocardiography to evaluate RV strain, which carries dramatically different mortality (52.4% vs 8.1% in stable patients) 2
• Monitor vital signs continuously: heart rate, blood pressure, oxygen saturation, and respiratory rate 2

If Hemodynamically Stable (Most Likely Scenario)

Maintain current apixaban therapy without modification, as DOACs like apixaban are non-inferior to traditional anticoagulation for PE treatment with lower bleeding risk 1:

• Do not add additional anticoagulation (no heparin, no increased apixaban dose) 1
• Do not administer thrombolysis, as systemic thrombolysis is not routinely indicated in intermediate- or low-risk PE 1
• Verify therapeutic dosing: confirm patient is receiving apixaban 10 mg twice daily for 7 days, then 5 mg twice daily 1

Supportive Care for Pulmonary Infarction

Provide symptomatic management for the localized lung injury:

• Analgesia for pleuritic chest pain: NSAIDs or opioids as needed 1
• Supplemental oxygen: maintain SpO2 >90% 4
• Monitor for complications: hemoptysis, pleural effusion, or secondary infection 1

Monitoring Strategy

Reassess clinical status at 48 hours using validated risk scores to determine if early discharge is appropriate 1:

• Serial vital signs: particularly heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation 1
• Watch for deterioration: worsening dyspnea, new hypotension, or increasing oxygen requirements 1
• Laboratory monitoring: renal function and hemoglobin to assess for bleeding complications 1

If Hemodynamically Unstable or Deteriorating

Administer rescue thrombolytic therapy immediately if the patient develops hemodynamic deterioration despite therapeutic anticoagulation 1, 3:

• Alteplase 100 mg IV over 2 hours via peripheral vein is the standard regimen 2, 3
• If cardiac arrest is imminent: give 50 mg alteplase IV bolus immediately 2, 3
• Stop apixaban during thrombolysis: resume anticoagulation 3 hours after alteplase completion with unfractionated heparin, then transition back to apixaban 2, 3

Alternative Advanced Interventions

Consider catheter-directed therapy or surgical embolectomy if thrombolysis is contraindicated or fails 1, 2:

• Catheter-assisted thrombus removal: for patients with absolute contraindications to thrombolysis 2
• Surgical pulmonary embolectomy: when shock is likely to cause death before thrombolysis can take effect 1, 2

Critical Pitfalls to Avoid

Do not switch from apixaban to warfarin or add heparin in stable patients, as this increases bleeding risk without improving outcomes 1, 4:

• Avoid therapeutic LMWH within 24 hours of potential thrombolysis: this significantly increases major bleeding risk if thrombolysis becomes necessary 4
• Do not routinely use inferior vena cava filters: these are not indicated in adequately anticoagulated patients 1

Do not delay intervention if deterioration occurs, as PE mortality reaches 7% within the first week even with treatment 4:

• Recognize that pulmonary infarction itself does not mandate thrombolysis: only hemodynamic instability or RV dysfunction does 1, 3
• Monitor for paradoxical embolism: though rare, thrombus can migrate through patent foramen ovale causing systemic complications 5

Duration of Anticoagulation

Plan for minimum 3 months of therapeutic anticoagulation for all patients with PE 1:

• Reassess at 3 months: discontinue if first episode with major transient/reversible risk factor 1
• Continue indefinitely: if recurrent VTE or no identifiable reversible risk factor 1
• Regular monitoring: assess drug tolerance, adherence, renal function, and bleeding risk at intervals 1