Abstract
BackgroundThe relative effectiveness of vitamin K antagonists compared with novel oral anticoagulants in treating pulmonary embolism remains unclear. Recent trials comparing the efficacy of vitamin K antagonists with factor Xa inhibitors for the treatment of pulmonary emboli have been non-inferiority studies based primarily on risk reduction (such as bleeding events), rather than resolution of specific diseases such as pulmonary embolism. Consequently, there is a lack of evidence indicating which of these agents are more effective. Here, we present a case where pulmonary emboli were treated with novel oral anticoagulants followed by warfarin to discuss the potential limitations in the use of novel oral anticoagulants as prevention or treatment of thromboembolism and the continued role for warfarin in this setting.Case presentationA 34-year-old African American woman presented to our clinic with shortness of breath and pleuritic chest pain several months post-surgery. She was identified as having multiple bilateral pulmonary embolisms and was treated with several novel oral anticoagulants, which failed to resolve the clots. Complete resolution was achieved upon switching to warfarin.ConclusionsThe patient described in this report failed to respond to novel oral anticoagulant therapy, but her emboli resolved when she was treated with warfarin. This study challenges the notion that factor Xa inhibitors are better alternatives to vitamin K anticoagulants in the treatment of pulmonary emboli based on their safety profile and ease of use alone. As a result, further post-marketing investigations into the efficacy of these agents in the management of pulmonary emboli may be warranted.
Highlights
The relative effectiveness of vitamin K antagonists compared with novel oral anticoagulants in treating pulmonary embolism remains unclear
The patient described in this report failed to respond to novel oral anticoagulant therapy, but her emboli resolved when she was treated with warfarin
This study challenges the notion that factor Xa inhibitors are better alternatives to vitamin K anticoagulants in the treatment of pulmonary emboli based on their safety profile and ease of use alone
Summary
For over 60 years, warfarin has been the standard outpatient management option for VTE. It has proven efficacy for this indication, significantly decreasing thromboembolic events while maintaining an acceptable level of adverse events, primarily bleeding episodes [1, 3] This has been confirmed by numerous prospective studies and in post-marketing clinical use, including trials conducted to compare the efficacy of conventional doses of warfarin with low doses for providing anticoagulation. Without significant retrospective analyses or randomized prospective trials with subgroup analyses, it is difficult to determine whether VKAs or FXaIs are truly more effective in the treatment of PE This assessment is especially difficult when taking into account the diagnostic modalities and treatments provided for this patient prior to arrival in our clinic.
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