Medical Management/Treatment

Initial primary anticoagulant treatment and transition to oral treatment are outlined in Table 2.4-6

Table 2. Intravenous and Oral Anticoagulation Therapy4-6

Initial hospital anticoagulant therapy
Enoxaparin 1 mg/kg subcutaneous dose every 12 hours or
Heparin 80 units/kg IV bolus followed by 18 units/kg/h IV infusion (adjust dose according to aPTT) or
Heparin 5000 unit bolus followed by 1333 units/h (adjust dose according to aPTT) or
Heparin 333 units/kg subcutaneously x 1, followed by 250 units/kg every 12 hours  
Transition to oral anticoagulant for discharge home
Apixaban 10 mg/d for 7 days then 5 mg twice a daya or
Dabigatran 150 mg twice dailya or
Rivaroxaban 15 mg twice a day for 21 days then 20 mg/da or
Warfarin 2-5 mg/d adjusted for target INR 2-3
aINR is not monitored to measure residual anticoagulation effect in this drug category.
aPTT, activated partial thromboplastin time; INR, international normalized ratio

Discussion/Follow-up Care

Patients who have COVID-19 infection compounded by an acute PE may require frequent follow-up and close monitoring after discharge by a pulmonary specialist. Medical management includes oral anticoagulants, and home oxygen therapy. Outpatient pulmonary rehabilitation may be required. If the patient is also diagnosed with DVT, use of antiembolic compression stockings is recommended upon discharge.

To read the first article in this series, on management of NSTEMI/STEMI in patients with COVID-19, click here.


Continue Reading

Deedra Harrington, DNP, MSN, APRN, ACNP-BC, is associate professor at the College of Nurse and Allied Health Professions, University of Louisiana at Lafayette. Dr Harrington is an advanced practice registered nurse-acute care who works with an inpatient cardiology intensivist group in Louisiana.

Frances Stueben, DNP, RN, CHSE, is an assistant professor and simulation program coordinator at the University of Louisiana at Lafayette. She teaches in the graduate and undergraduate nursing programs.

Christy L. McDonald Lenahan, DNP, FNP-BC, ENP-C, CNE, is an advanced practice registered nurse in family and emergency medicine who works for an emergency medicine and hospitalist staffing agency. She is also an associate professor at the University of Louisiana at Lafayette and teaches in the masters and doctoral programs.

References

  1. Rao RK, Crawford MH. Pulmonary embolic disease. In: Current Diagnosis & Treatment: Cardiology. 5th ed. McGraw-Hill Education; 2017:385-401.
  2. Ortega-Paz L, Capodanno D, Montalescot G, Angiolillo DJ. Coronavirus disease 2019 associated thrombosis and coagulopathy: review of the pathophysiological characteristics and implications for antithrombotic management. J Am Heart Assoc. 2021;10(3):e019650. doi:10.1161/JAHA.120.019650
  3. Dhakal BP, Sweitzer, NK, Indik, JH, Acharya D, William P. SARS-CoV-2 infection and cardiovascular disease: COVID-19 heart. Heart Lung Circ. 2020;29(7):973-987. doi:10.1016/j.hlc.2020.05.101
  4. Kearon C, Akl EA, Ornelas J. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149(2):315-352. doi:10.1016/j.chest.2015.11.026.
  5. Garcia DA, Baglin TP, Weitz JI, Samama MM. Parenteral anticoagulants: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 suppl):e24S-e43S. doi:10.1378/chest.11-2291 [published corrections appear in Chest. 2012;141(5):1369; Chest. 2013;144(2):721]. 
  6. Panahi L, Udeani G, Horseman M, et al. Review of medical therapies for the management of pulmonary embolismMedicina. 2021;57(2):110. doi:10.3390/medicina5702011