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3. Evidence Grading Topic review Recommendations Home Contactus AboutUpToDate Help U ToDate New Search Up ONLINE 16 1 D sa Clear LOGIN New Search Patient Info What s New FEEDBACK cw af f A h Find in Topic Print This Topic Anticoagulation in acute pulmonary embolism EA Pt Patient Info Email This Topic i SUMMARY AND RECOMMENDATIONS SPECIAL CONSIDERATIONS e Pregnancy e Cancer We recommend that anticoagulation be initiated immediately in patients with a high clinical suspicion of pulmonary embolism PE and continued during the diagnostic evaluation show figure 1 Grade 1B See Initiation of therapy above and see Treatment of acute pulmonary embolism INFORMATION FOR PATIENTS We recommend that anticoagulation be initiated using subculilaneous low moleculag weight heparin SC LMWH or intravenous unfractionated heparin IV UFH In SUMMARY AND RECOMMENDATIONS hemodynamically stable patients with PE we recommend SC LMWH Grade 14A In c ntrast we suggest Iv UFH for patients with persistent hypotension due to PE ie massive PE or severe renal failure Grade 2C There are no ag aol st use of one LMWH preparation over another See Initiation of therapy above see Low molecular weight heparin above section on Clinical evidence and see Unfractionated heparin
4. 3 Date 4 Reference MR a Medline Abstracts b 253 Outline Reference Medline Abstracts 5 Graphics A x WA E7 a ZEAR RU B GLAD MATHER bART AS FR FIA email 6 Drug Information Lexi comp 7 Related Topics UpToDate z j8 hA 285 Topic revleWwW Related Topic RA is Hatin ase babies wanna EMEN DOES 9 Patient Info Patient Information Information for patients Home Contactus AboutUpToDate Help U ToDate New Search Up ONLINE 16 1 pet Go Clear ee FEEDBACK New Search Patient Info What s New ry itt Find in Topic ey Print This Topic Anticoagulation in acute pulmonary embolism s UU Pati
5. Go Drug Interactions Lexi Comp a email TY Bei Home erum Homepage Contact us UpToDate About UpToDate UpToDate Pj 35 8H Help 3 4 5 6 7 8 New Search 48 448 1 PRA XE symptoms amp procedures 44 drugs gt 1aboratory abnormalities 2 UpToDate uaia amp 7 synonyms amp amp abbreviations or acronyms word roots 3 UpToDate 4 in adults in children n in pregnancy New Search 1 New Search a treatment of hypertension in pregnancy gt warfarin and PE A E amp Jk P5 38 25 4p 2 4 28 D 45 47H 50 50 m AA Topic Outiline Topic HEA A ABBE A Outline zit amp Home Contactus AboutUpToDate H
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7. OF THERAPY LOW MOLECULAR WEIGHT HEPARIN Dosing Therapeutic use of heparin and low molecular weight heparin Extreme obesity e Monitoring e Clinical evidence Thrombotic complications of chronic hemodialysis vascular access Fistulas and grafts Cost effectiveness Therapeutic uses of recombinant coagulation factor Vila Atrial septal abnormalities PFO ASD and A54 and risk of cerebral emboli in adults Management of inherited thrombophilia Preoperative evaluation and perioperative management of patients with rheumatic diseases UNFRACTIONATED HEPARIN Treatment and prognosis of cerebral venous thrombosis e Dosing t 1 E e Monitoring Thrombosis associated with chronic hemodialysis vascular access Catheters e clinic aiden Chemotherapy in hormone resistant prostate cancer OTHER ANTICOAGULANTS Therapeutic use of fondaparinux WARFARIN Rhythm control versus rate control in atrial fibrillation e Initiation e Dosing e Monitoring Antiphospholipid syndrome and the kidney e Clinical evidence Paroxysmal atrial fibrillation Total hip arthroplasty COMPLICATIONS Bleeding Heparin Warfarin Total knee arthroplasty Topic review 1 Outline REBAR gt TRE B fe Rb Wie dE BRE 2 Author Section Editor Deputy Editer Topic review pp
8. above section on Clinical evidence GRAPHICS tdg A When IV UFH is administered we suggest that the dose be adjusted to maintain aPTT prolongation that corresponds to plasma heparin levels from 0 3 to 0 7 U mL FIGURES anti Xa activity by amidolytic assay Grade 2C The target range is generally 1 5 to 2 5 times the control aPTT When SC LMWH is administered anti factor Xa levels PE treatment algorithm should not be monitored See Low molecular weight heparin above and see Unfractionated heparin above sections on Monitoring TABLES Warfarin can be initiated at the same time or following the initiation of heparin We recommend therapy with heparin for at least five days Grade 1C We Heparin protocol I recommend that heparin not be discontinued before the INR is stable and 2 0 for at least two consecutive days Grade 1A See Initiation above Heparin protocol II CRI F Evidence Grading gt 47 E E P575 2 Grade 1A amp Grade 2C gt amp Ik H 38 8828 UpToDate ONLINE 16 1 2008 UpToDate E e mail this graphic Grade 14 recommendation A Grade 1A recommendation is a strong recommendation and applies to most patients in most circumstances without reservation Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present Explanation A Grade 1 recommendation is a
9. DUCTION Anticoagulation is the main therapy for acute pulmonary embolism PE Its goal is to decrease m io Cancer Anticoagulation in acute pulmonary embolism Deputy Editor Kevin C Wilson MD PE Russell D Hull MBBS MSc Last literature review version 16 1 January 2008 This topic last updated November 8 2007 More ting recurrent PE In the only trial ever performed comparing untreated patients with PE versus those who were treated with anticoagulan with decreased mortality 1 c Subsequent uncontrolled trials have confirmed that anticoagulation is associated with decreased mrtality 2 T INFORMATION FOR 4 b SUMMARY AND RECO Common questions asked by clinicians caring for patients with acute PE include REFERENCES Should I initiate anticoagulant therapy GRAPHICS FIGURES Which anticoagulant should I initiate e What is the appropriate dose e How should I monitor the treatment PE treatment algorithm What is the clinical evidence supporting its use What are the common complications B 4 UpToDate ONLINE 16 1 New Search Patient Info Anticoagulation in acute pulmonary embolism INFORMATION FOR PATIENTS SUMMARY AND RECOMMENDA REFERENCES Sip 5 GRAPHICS FIGURES PE treatment algorithm TABLES Heparin protocol I Heparin protocol II Weight based heparin nomogram RELATED TOPICS Treatment of acute pulmonary embolism Inferior vena caval f
10. Last literature review version 16 1 January 2008 This topic last updated November 8 2007 More INTRODUCTION Anticoagulation is the main therapy for acute pulmonary embolism PE Its goal is to decrease mortality by preventing recurrent PE In the only trial ever performed comparing untreated patients with PE versus those who were treated with anticoagulants anticoagulation was associated with decreased mortality 1 Subsequent uncontrolled trials have confirmed that anticoagulation is associated with decreased mortality 2 4 Common questions asked by clinicians caring for patients with acute PE include Home Contactus AboutUpToDate Help New Search O M Go Clear LOG IN FEEDBACK We found 53 instances of warfarin Find Again Cancel Find In Topic opic Ww Dra Sry VEIT See Te Sr D IU RUE MEE GI Spr ror ner Serer apy ror Gee ung oru confirmatory trials are reported See Therapeutic use of fondaparinux filiis In most cases initial heparin therapy is administered short term then transitioned to a long term orally active anticoagulant Most oral anticoagulants are vitamin K antagonists that suppress the production of the vitamin K dependent clotting factors II VII IX and X Although several vitamin K antagonists exist ETIUETIIU is the most common and best studied thus it is the focus of our discussion There are circumstances in which SC LMWH may be continued long
11. elp UpToDate ONLINE 16 1 LOG IN New Search Patient Info What s New FEEDBACK New Search warfarin and pel Bie Clear Drug Interactions New Search Help You may search on a single term or on multiple terms at the same time e g Treatment of hypertension in children Home Contactus About UpToDate Help UpToDate New Search wararnandp Ss Go Clear ONLINE 16 1 wartarin and pe UNT New Search Patient Info What s New FEEDBACK pe means pulmonary embolism Alternates etoposide cisplatin Search Results for warfarin and pe Topic Outline NTRODUCTION NITIATIOM OF THERAPY LOW MOLECULAR WEIGHT HEPARIN e Dosing Treatment of acute pulmonary embolism Management of anticoagulation before and after elective surgery Deep vein thrombosis and pulmonary embolism in preanancy Extreme obesity e Monitoring e Clinical evidence Low molecular weight heparin for venous thromboembolic disease e Cost effectiveness Anticoagulation during pregnancy Home Contactus About UpToDate Help U ToDate New Search p ONLINE ii warfarin and pe paf Go Clear LOG IN New Search Patient Info What s New FEEDBACK pe means pulmonary embolism Alternates etoposide cisplatin Search Results for warfarin and pe Topic Outline por Ed Upper enu enny YCIIOUOD CI ocITipD o dI Treatment for specific causes of ischemic stroke and transient ischemic attack INTRODUCTION INITIATION
12. em s Lookup to Analyze for potential interactions between items in the list Remove item from the list by clicking the check mark next to the item name risk ratings Lexi Comp Online Interaction Analysis Customize Analysis Only interactions at or above the select d risk rating wilfbe displayed A View interaction detail by clicking on link Aspirin D Grape Seed Herbs Anticoagulant Antiplatelet Properties Grape Seed D Aspirin Salicylates Date August 16 2005 Disclaimer Readers are advised that decisions regarding drug therapy must be based on the independent judgment of the clinician changing information about a drug eg as reflected in the literature and manufacturer s most current product information and changing medical practices 4 Risk Rating Risk Rating A B C D X Risk Rating Rapid indicator regarding how to respond to the interaction data Each Interact monograph is assigned a risk rating of A B C D or X The progression from A to X is accompanied by increased urgency for responding to the data In general A and B monographs are of academic but not clinical concern Monographs rated C D or X always require the user s attention The text of the Patient Management section of the monographs will provide assistance regarding the types of actions that could be taken The defini
13. ent Info J Email This Topic TOPIC OUTLINE INTRODUCTION Author Section Editor INITIATION OF THERAPY LOW MOLECULAR WEIGHT HEPARIN e Dosing Extreme e Monitoring Deputy Editor Karen Valentine MD PhD Jess Mandel MD Kevin C Wilson MD Last literature review version 16 1 January 2008 This topic last updated November 8 2007 More i ity by preventing recurrent PE In the only trial ever obesity js associated with decreased mortality 1 performed comparing untreated patients with PE versus those who were treated with anticoagulants antica e Clinical evidence Subsequent uncontrolled trials have confirmed that anticoagulation is associated with decreased mortality 2 4 e Cost effectiveness Common questions asked by clinicians caring for patients with acute PE include UNFRACTIONATED HEPARIN e Dosing e Monitoring e Should I initiate anticoagulant therapy Which anticoagulant should I initiate Home Contactus AboutUpToDate Help U ToDate New Search up ONLINE 16 1 Ba Go Clear NU New Searc h Patient Info What s New FEEDBACK e Find in Topic E Print This Topic Anticoagulation in acute pulmonary embolism we Patient Info BY Email This Topic e First episode of PE Reversible risk factor Idiopathic Author Section Editor Irreversible risk factor Karen 4 Valentine MD PhD Jess Mandel MD Recurrent SPECIAL CONSIDERATIONS e Pregnancy INTRO
14. ers and see Fibrinolytic thrombolytic therapy in pulmonary embolism and deep vein thrombosis aet i D E n Correcting excess anticoagulation after Help improve UpToDate Did this topic answer your question Yes No UpToDate ONLINE 16 1 You ve chosen to send the following topic review Anticoagulation in acute pulmonary embolism 1 Fill in e mail information 2 Include a message guest pass 3 Send topic four e mail address will nat Message Edit if desired eras ene Below is a topic review taken from UpToDate Send marketing purposes See Our that I thought you might find interesting privacy policy Your name UpToDate is a clinical information service fs that has thousands of topic reviews such as this one designed to give immediate answers d m to clinical questions Visit them on the weh Your e mail es at wwwy uptodate caom Send a copy to me E mail address of recipient Wotodate quest pass Sy l Please include a one time complimentary 30 day guest separate multiple pass to UnToDate along with the topic review addresses with commas limit of one quest pass per recipienti El Required fields B Drug Interactions Lexi Comp drug to drug herb to herb drug to herb 1
15. hould I initiate What is the appropriate dose How should I monitor the treatment What is the clinical evidence supporting its use Fibrinolytic thrombolytic therapy in What are the common complications pulmonary embolism and deep vein For how long should I treat thrombosis Treatment of acute pulmonary embolism Inferior vena caval filters Low molecular weight heparin for venous We discuss the initiation of anticoagulant therapy the different types of anticoagulants transition to oral anticoagulants and duration of therapy here In addition thromboembolic disease complications and risk factors for complications are reviewed Much of the data presented are from studies that did not distinguish patients with acute PE from patients with Therapeutic use of heparin and low acute deep vein thrombosis DVT instead grouping the diseases together as venous thromboembolic disease VTE This is reflective of the opinion that both DYT and PE are molecular weight heparin clinical manifestations of a single clinical entity amp s a result most of the opinions suggestions and recommendations within our discussion are equally applicable to patients Therapeutic use of fondaparinux with acute DVT Therapeutic use of warfarin The treatment of acute pulmonary embolism including thrombolysis inferior vena caval filters and embolectomy is reviewed elsewhere See Treatment of acute pulmonary Protein C deficiency embolism see Inferior vena caval filt
16. ialty using the enclosed software you agree to UpToDate s URLs Our URLs have changed To become bound by the terms of this access UpfoDate go to Subscription and License Agreement this www uptodate com online Agreement If you do not agree to these Calculators Type calculators into the search terms do not open the package and promptly screen to view a complete list Patient Information UpToDate launches UpToDate for Patients By clicking the accept button below you agree to the terms and conditions of the Subscription and Newsletter Read more about version 16 1 IERI REESE UU JEU UY DU J L RU c Joseph M Rush MD Published Since 1992 Subscription and License Agreement Support Tag ecapp0502p utd com 68 236 108 2 1F1F8923EF 979 Licensed to UpToDate APA UpToDate 3 DNLINE 16 1 FEEDBACK 7 New Search Patient Info What s New 4 New Search ba se Clear Drug Interactions p 1 New Search 2 Patient Information UpToDate 130 Patient information Patient information patient info hypertension What s New 2 RRMA Xx 48d SR a E R g R A a BRAK ZH New Search
17. ilters Fibrinolytic thrombolytic therapy in pulmonary embed p vein thrombosis Low molecular n for venous thromboemboli Therapeutic use of heparin and low molecular weight heparin Therapeutic use of fondaparinux Therapeutic use of warfarin UpToDate ONLINE 16 1 2008 UpToDate UpToDate ONLINE 16 1 New Search Patient Info What s New What s New Home Contactus AboutUpToDate Help New Search O O O Go Clear LOG IN FEEDBACK Bl o Find in Topic G Patient Info Print This Topic BY Email This Topic Should I initiate anticoagulant therapy Which anticoagulant should I initiate What is the appropriate dose How should I monitor the treatment What is the clinical evidence supporting its use What are the common complications For how long should I treat We discuss the initiation of anticoagulant therapy the different types of anticoagulants transition to oral anticoagulants and duration of therapy here In addition complications and risk factors for complications are reviewed Much of the data presented are from studies that did not distinguish patients with acute PE from patients with acute deep vein thrombosis DVT instead grouping the diseases together as venous thromboembda E This is reflective of the opinion that both DVT and PE are clinical manifestations of a single clinical entity As a result most of the opinions suggestions and r 7 ons
18. ise myocardial perfusion imaging in the diagnosis and prognosis of coronary heart disease esting for the diagnosis of coronary heart disease in women Pharmacologic stress myocardial perfusion imaging in the diagnosis and prognosis of coronary heart disease 11
19. ng Members Risk Rating References and more Disclaimer Vhile great care has been taken to ensure the accuracy of the information presented the user is advised that the authors editors reviewers contributors and publishers cannot be responsible for the continued currency of the information or for any errors omissions or the application of this information or for any consequences arising therefrom Therefore the author s and or the publisher shall have no liability to any person or entity with regard to claims loss or damage caused or alleged to be caused directly or indirectly by the use of information contained herein Because of the dynamic nature of drug information readers are advised that decisions regarding drug therapy must be based on the independent judgment of the clinician changing information about a drug eg as reflected in the literature and manufacturer s most current product information and changing medical practices The editors are not responsible for any inaccuracy of quotation or for any false or misleading implication that may arise due to the text or formulas as used or due to the quotation of revisions no longer official JABS amp Qr RER a 8 ON LINE Lexi Interact gt s Lookup Enter item name to lookup Analyze New List Iv Aspirin 7 Grape Seed Display complete list of interactions for an individual item by clicking item name Add another it
20. nical suspicion of PE but a strong contraindication to antico Se gnostic evaluation should be expedited Anticoagulation independent therapies eg inferior vena caval filter should be pursued once PE is confirrded show figure 1 Bee Treatment of acute pulmonary 4 e mail this graphic Treatment algorithm for patients with suspected pulmonary embolism Stabilize the patient Anticoagulation contraindicated Anticoagulation with SC LMWH or IV UFH Diagnostic evaluation PE excluded PE confirmed Diagnostic evaluation PE excluded No further evaluation PE confirmed Inferior vena caval filter Home Contactus AboutUpToDate Help New Search LOGIN FEEDBACK Print This Topic Anticoagulation in acute pulmonary embolism o TOPIC OUTLINE INTRODUCTION INITIATION OF THERAPY LOW MOLECULAR WEIGHT HEPARIN e Dosing Extreme obesity Monitoring Clinical evidence Cost effectiveness UpToDate ONLINE 16 1 New Search Patient Info What s New Anticoagulation in acute pulmonary embolism p Initiation Dosing Monitoring Clinical evidence COMPLICATIONS Bleeding Heparin Warfarin Management Thrombocytopenia DURATION OF THERAPY Email This Topic Anticoagulation in acute pulmonary embolism Section Editor Jess Mandel MD Author Karen 4 Valentine MD PhD Russell D Hull MBBS MSc Deputy Editor Kevin C Wilson MD
21. strong recommendation It means that we believe that if you follow the recommendation you will be doing more good than harm for most if not all of your patients Grade 4 means that the best estimates of the critical benefits and risks come from consistent data from well performed randomized controlled trials or overwhelming data of some other form eg well executed observational studies with very large treatment effects Further research is unlikely to have an impact on our confidence in the estimates of benefit and risk Recommendation grades 1 Strong recommendation Benefits clearly outweigh the risks and burdens or vice versa for most if not all patients 2 Weak recommendation Benefits and risks closely balanced and or uncertain Evidence grades A High quality evidence Consistent evidence from randomized trials or overwhelming evidence of some other form B Moderate quality evidence Evidence from randomized trials with important limitations or very strong evidence of some other form C Low quality evidence Evidence from observational studies unsystematic clinical observations or from randomized trials with serious flaws For a complete description of our grading system please see the UpToDate editorial policy that can be found by clicking on Help and then About UpToDate ik Evidence Grading 10 Ju Calculators UpToDate 60
22. te guest pass email 30 email UpToDate Home Contactus About UpToDate Help ONLINE 16 1 LOG IN New Search Patient Info What s New FEEDBACK h Find in Topil E Print This Topic Anticoagulation in acute pulmonary embolism i JU Patient Info BY Email This Topic INFORMATION FOR PATIENTS SUMMARY AND RECOMMENDATIONS REFERENCES Anticoagulation in acute pulmonary embolism Author Section Editor Deputy Editor Karen 4 Valentine MD PhD Jess Mandel MD Kevin C Wilson MD GRAPHICS Russell D Hull MBBS MSc FIGURES Last literature review version 16 1 January 2008 This topic last updated November 8 2007 More e PE treatment algorithm INTRODUCTION Anticoagulation is the main therapy for acute pulmonary embolism PE Its goal is to decrease mortality by preventing recurrent PE In the only trial ever TABLES performed comparing untreated patients with PE versus those who were treated with anticoagulants anticoagulation was associated with decreased mortality 1 e Heparin protocol I Subsequent uncontrolled trials have confirmed that anticoagulation is associated with decreased mortality 2 4 Heparin protocol II Common questions asked by clinicians caring for patients with acute PE include Weight based heparin nomogram Should I initiate anticoagulant therapy RELATED TOPICS Which anticoagulant s
23. term rather than transitioning to oral EWE including pregnancy and malignancy Long term SC LMWH is an option for other patients as well but is generally prohibited by cost See Pregnancy below and see Cancer below Initiation Efe can be started on the same day or after heparin but should not be initiated prior to heparin because use of FREE alone has been associated with a three fold increased incidence of recurrent PE or DYT 12 45 This is primarily because as noted below full anticoagulation with FREE requires about five days of treatment Simultaneous initiation of heparin and TUET therapy is effective and shortens hospital stays with major cost savings 46 47 Heparin therapy should be overlapped with felarnis for a minimum of five days and continued until the International Normalized Ratio INR has been within the therapeutic range 2 0 to 3 0 for at least two consecutive days 13 We believe that heparin therapy should be extended in cases of persistent hypotension due to PE ie massive PE or extensive iliofemoral thrombosis 1 Print This Topic Topic review 2 Email This Topic email Topic review Related Toplc 3 UpToDa
24. tion of each risk rating is as follows Lexi Interact Enter item name to lookup Analyze New List Aspirin Grape Seed LEXI COMP Lookup Display complete list of interactions for an individual item by clicking item name Add another item s Lookup to Analyze for potential interactions between items in the list Remove item from the list by clicking the check mark next to the item name Risk Rating A No Known interaction Action No Action Needed Monitor Therapy Consider Therapy Modification Description Data have not demonstrated either pharmacodynamic or pharmacokinetic interactions between the specified agents Data demonstrate that the specified agents may interact with each other but there is little to no evidence of clinical concern resulting from their concomitant use Data demonstrate that the specified agents may interact with each other in a clinically significant manner The benefits of concomitant use of these two medications usually outweigh the risks An appropriate monitoring plan should be implemented to identify potential negative effects Dosage adjustments of one or both agents may be needed in a minority of patients Data demonstrate that the two medications may interact with each other in a clinically significant manner A patient specific assessment must be conducted to determine whether the benefits of
25. within our discussion are equally applicable to patients with acute DYT The treatment of acute pulmonary embolism including thrombolysis inferior vena caval filters and embolectomy is reviewed elsewhere See Treatment of acute pulmonary embolism see Inferior vena caval filters and see Fibrinalytic thrombolytic therapy in pulmonary embolism and deep vein thrombosis 1 DIN O HFRADPY PE has been confirmed because we believe that the high incidence_o of major bleeding less than three percent 9 In contrast antici clinical suspicion of PE is low to moderate We recommend hal ar De It n all Pater Or WhOM Chere d Migr nical SUSPICION OF puirmoriary emoo nN tr OF in who due to recurrent PE in untreated patients approximately 30 percent 5 8 outweighs the risk apy should be considered on a case by case basis when PE has not been confirmed and the The efficacy of anticoagulant therapy depends upon achieving a thera be initiated immediately after it has determined that it is indicated Anticoagulation should be initiated using subcutaneous low molecular weight heparin SC LMWH or intravenous unfractionated heparin IV UFH 13 We prefer SC LMWH in hemodynamically stable patients with PE In contrast we use IV UFH in patients with persistent hypote PE ie massive PE or severe renal failure See Low molecular weight heparin below and see Unfractionated heparin below In the rare patient in whom there is a high cli
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