Chest Pain and Shortness of Breath in a 33-Year-Old Man

Jason Chang, MD; Linda Chun, MD


July 20, 2020

Acute pulmonary embolism requires initial short-term therapy with a rapid-onset anticoagulant, followed by therapy with a vitamin K antagonist for at least 3 months; in patients at high risk for recurrence, extended therapy is required. In patients with a high clinical probability of pulmonary embolism, anticoagulant treatment should be initiated while diagnostic confirmation is awaited.

Treatment should be initiated with subcutaneous low-molecular-weight heparin, fondaparinux, or intravenous unfractionated heparin. Vitamin K antagonists should be initiated as soon as possible, preferably on the first treatment day, and heparin should be discontinued when the international normalized ratio has been 2 or higher for at least 24 hours.

Hemodynamically unstable patients are candidates for more aggressive treatment, such as pharmacologic or mechanical thrombolysis. Major contraindications to thrombolytic therapy include intracranial disease, uncontrolled hypertension, and recent major surgery or trauma.

Percutaneous mechanical thrombectomy (thrombus fragmentation and aspiration) and surgical embolectomy should be restricted to high-risk patients with an absolute contraindication to thrombolytic treatment and those in whom thrombolytic treatment has not improved hemodynamic status.

The use of vena cava filters should be reserved for patients with contraindications to anticoagulant treatment or who have developed pulmonary embolism despite anticoagulation. Patients with acute pulmonary embolism are at risk for recurrent thromboembolic events, mainly a second pulmonary embolism.

The duration of long-term anticoagulation should be based on the risk for recurrence after cessation of treatment with vitamin K antagonists, the risk of bleeding during treatment, and the patient's preference. In patients with pulmonary embolism secondary to a temporary (reversible) risk factor, therapy with vitamin K antagonists should be given for 3 months. Patients with unprovoked pulmonary embolism, those with cancer, and those with recurrent unprovoked pulmonary embolism are candidates for indefinite anticoagulation with periodic reassessment of the risk-benefit ratio.

Direct oral anticoagulants (DOACs) such as dabigatran, an oral antithrombin agent with a more predictable anticoagulant effect and reduced drug interactions compared with warfarin, have been found to be effective and safe for the treatment of venous thromboembolism.[7,8] Research has found no substantial differences between DOACs and standard anticoagulation for long-term treatment of pulmonary embolism in terms of safety and outcomes.[9] DOACs are now well studied and have shown to be at least as effective at vitamin K antagonists, with more predictable anticoagulation, less bleeding, less drug-drug interactions, and no need to bridge with heparin or to perform frequent laboratory testing.

At the time of this case, the patient was started on warfarin with a heparin bridge. His bowel function returned, and the patient was discharged to home with a plan for 3 months of warfarin treatment. He was scheduled for a postoperative visit shortly thereafter.


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