Should anti-vitamin K be started on the first day in non-high risk pulmonary embolism?

Abstract

Introduction. Protocols and Guidelines have been improving results of our clinical practice. Sometimes there have been differences between guidelines on the same topic, but they have not been so important usually. As far as the start of vitamin K antagonist (VKA) in a non-high risk pulmonary thromboembolism (PTE) patient is concerned, there is global consensus (reflected in all comprehensive guidelines) that it should be on the admission day or a day later. However, there are situations in which this administering VKA from the first (or second) day of hospitalization may actually complicate the treatment. Case report. As an illustration, our female, 71 years old patient with second unprovoked, intermediate-high risk PTE was given low -molecular -weight -heparin (LMWH) + VKA from the second day. Due to lack of improvement in symptoms, oxygen saturation and D dimer after 9 days, Computerized tomography pulmonary angiography (CTPA) was repeated and it confirmed minimal advancement. She already had achieved target international normalized ratio (INR) and it complicated proceeding to fibrinolytic therapy. Conclusion. Therefore, correction of the therapeutic approach may be needed even if the treatment is completely according to the latest guidelines. We suggest postponing VKA from the first (or second) day of hospitalization (as suggested in all available guidelines for non-high risk PTE patients) until satisfying clinical improvement is reached.Key words: pulmonary thromboembolism, anticoagulant therapy, computed tomography pulmonary angiography, D-dimer. ApstraktUvod. Protokoli i smernice poboljšavaju rezultate naše kliničke prakse. Ponekad postoje razlike između preporuka o istoj temi, ali te razlike obično nisu toliko važne. Što se tiče početka primene antagonista vitamina K (VKA) u PTE pacijenta sa visokim rizikom, postoji globalni konsenzus (koji se ogleda u svim savremenim smernicama) da bi to trebalo da bude na dan prijema ili dan kasnije. Međutim, postoje situacije u kojima davanje VKA od prvog (ili drugog) dana hospitalizacije može zapravo komplikovati tretman. Prikaz bolesnika. Kao ilustracija, naša 71godišnja pacijentka, sa drugom neprovociranom PTE srednjeg rizika, je dobila LMVH + VKA od drugog dana. Zbog izostanka poboljšanja simptoma, saturacije kiseonikom i D dimera nakon 9 dana, ponovljen je CTPA i on je potvrdio minimalan napredak. Ona je već postigla ciljni INR i to je komplikovalo prelazak na fibrinolitičku terapiju. Zakljuĉak. Stoga, korekcija terapijskog pristupa može biti potrebna čak i kad je lečenje potpuno u skladu sa savremenim preporukama. Sugerišemo odlaganje VKA od prvog (ili drugog) dana hospitalizacije (kao što se preporučuje u svim raspoloživim vodičima za pacijente sa PTE koji nisu na visokom riziku), dok se ne postigne kliničko poboljšanje. Kljuĉne reĉi:plućna tromboembolija, antikoagulantna terapija, pulmonalna angiografija kompjuterizovanom tomografijom, D-dimer.